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The Relationship Between Emergency Department Crowding and Patient Outcomes: A Systematic Review
Abstract
Emergency department (ED) crowding is a significant patient safety concern associated with poor quality of care. The purpose of this systematic review is to assess the relationship between ED crowding and patient outcomes.
We searched the Medline search engine and relevant emergency medicine and nursing journals for studies published in the past decade that pertained to ED crowding and the following patient outcome measures: mortality, morbidity, patient satisfaction, and leaving the ED without being seen. All articles were appraised for study quality.
A total of 196 abstracts were screened and 11 articles met inclusion criteria. Three of the eleven studies reported a significant positive relationship between ED crowding and mortality either among patients admitted to the hospital or discharged home. Five studies reported that ED crowding is associated with higher rates of patients leaving the ED without being seen. Measures of ED crowding varied across studies.
ED crowding is a major patient safety concern associated with poor patient outcomes. Interventions and policies are needed to address this significant problem.
This review details the negative patient outcomes associated with ED crowding. Study results are relevant to medical professionals and those that seek care in the ED.
... Both metrics have demonstrated a strong association with clinician opinions of crowding, patients leaving without being seen, and ambulance diversion [19]. Moreover, both have proven studied impacts based on quantitative capacity and usage metrics and correlate with perception of care and objective crowding [24]. Nonetheless, in their current state these measures are effective tools to investigate crowding in global EDs and to investigate causes and possible interventions. ...
... Lesser effects of crowding include delayed time to assessment, decreased quality of care, or medication errors which may cumulate in low patient satisfaction [11]. Crowding can also cause increased walkouts prior to receiving care, which may contribute to an increased chance of readmission and prolonged time in the hospital [14,24,25]. These patient factors are further exacerbated by the impacts that crowding has on the healthcare system. ...
... In some cases, this association is profound; one study showed that for every 5 h spent in the ED, chance of mortality increased by over 50% [36]. Chances of poor outcomes are increased, because crowding is associated with poorer service delivery, patients leaving without being seen, and staff burnout [3,24,33,37]. ...
Crowding in Emergency Departments (EDs) has emerged as a global public health crisis. Current literature has identified causes and the potential harms of crowding in recent years. The way crowding is measured has also been the source of emerging literature and debate. We aimed to synthesize the current literature of the causes, harms, and measures of crowding in emergency departments around the world. The review is guided by the current PRIOR statement, and involved Pubmed, Medline, and Embase searches for eligible systematic reviews. A risk of bias and quality assessment were performed for each review, and the results were synthesized into a narrative overview. A total of 13 systematic reviews were identified, each targeting the measures, causes, and harms of crowding in global emergency departments. Key among the results is that the measures of crowding were heterogeneous, even in geographically proximate areas, and that temporal measures are being utilized more frequently. It was identified that many measures are associated with crowding, and the literature would benefit from standardization of these metrics to promote improvement efforts and the generalization of research conclusions. The major causes of crowding were grouped into patient, staff, and system-level factors; with the most important factor identified as outpatient boarding. The harms of crowding, impacting patients, healthcare staff, and healthcare spending, highlight the importance of addressing crowding. This overview was intended to synthesize the current literature on crowding for relevant stakeholders, to assist with advocacy and solution-based decision making.
... This 5-point Likerttype scale has the following response categories: 5 = I totally agree, 4 = I agree, 3 = I partially agree, 2 = I disagree, 1 = I totally disagree. Ten items (21,36,37,38,39,40,41,42,43,45) are negatively scored. Total scores range between 46 and 230. ...
... Emergency services in hospitals can be defined as potentially risky areas, where patient safety is under threat and medical errors are more common (34). In addition, they are highly complex units with the highest patient load compared with other departments (35)(36)(37)(38); the workload is uncontrolled and unpredictable (34,39,40). Doctors and nurses working in the emergency service are under intense physical and mental pressure (35,41), for instance, the time pressure is very high, and decisions are usually made under pressure (40,41). ...
Background: Nurses have a key role in ensuring the safety of patients, reducing the likelihood of errors and improving patient outcomes. Aims: This study aimed to determine the factors affecting patient safety, with a focus on the culture and attitudes of nurses working in emergency units. Method: This cross-sectional, descriptive, correlational study was conducted between 10 January and 30 August 2015 among 282 nurses who worked at emergency units of 19 hospitals in the north-central Black Sea Region of Turkey. Data were obtained using descriptive information forms, the Patient Safety Attitude Scale (PSAS) and the Patient Safety Culture Scale (PSCS). Results: The mean total PSAS score was 152.26 [standard deviation (SD) 22.54; range 46–230], while the mean total PSCS score was 2.56 (SD 0.52; range 1–4). Around a quarter of the participants reported errors, such as medication errors and patient falls, which threatened patient safety in the emergency units. The case report forms were not filled when these errors occurred. Conclusion: Attitude and culture of nurses in hospital emergency units towards patient safety differed according to their sociodemographic and work–life characteristics, including being satisfied with working in the emergency room, quality of work–life, level of job satisfaction, and number of years working in the emergency room.
... However, this work also considers the possibilities of patient evasion and death, as well as the triage redirection. Death and evasion may occur at any stage of the process (Carter et al., 2014), and should be considered in the analysis of ED processes and simulations. These different outputs were specified to represent connections with other hospital areas. ...
Purpose
This work aims to integrate the concepts generated by a systematic literature review on patient flows in emergency departments (ED) to serve as a basis for developing a generic process model for ED.
Design/methodology/approach
A systematic literature review was conducted using PRISMA guidelines, considering Lean Healthcare interventions describing ED patients’ flows. The initial search found 141 articles and 18 were included in the systematic analysis. The literature analysis served as the basis for developing a generic process model for ED.
Findings
ED processes have been represented using different notations, such as value stream mapping and workflows. The main alternatives for starting events are arrival by ambulance or walk-in. The Manchester Triage Scale (MTS) was the most common protocol referred to in the literature. The most common end events are admission to a hospital, transfer to other facilities or admission to an ambulatory care system. The literature analysis allowed the development of a generic process model for emergency departments. Nevertheless, considering that several factors influence the process of an emergency department, such as pathologies, infrastructure, available teams and local regulations, modelling alternatives and challenges in each step of the process should be analysed according to the local context.
Originality/value
A generic business process model was developed using BPMN that can be used by practitioners and researchers to reduce the effort in the initial stages of design or improvement projects. Moreover, it’s a first step toward the development of generalizable and replicable solutions for emergency departments.
... The importance of maintaining good patient flow cannot be understated. Carter, Puch and Larson in their literature review of emergency department (ED) crowding found that ED overcrowding has a significant positive correlation with patient mortality and with patients leaving the hospital untreated [8]. Morley et al. in their literature review also found an increase in patient mortality, as well as a higher exposure to error, poorer patient outcomes and increased patient length of stay, both in the ED, and in the ward to which a patient is eventually assigned [20]. ...
We study the Patient Assignment Scheduling (PAS) problem in a random environment that arises in the management of patient flow in the hospital systems, due to the stochastic nature of the arrivals as well as the Length of Stay distribution. We develop a Markov Decision Process (MDP) which aims to assign the newly arrived patients in an optimal way so as to minimise the total expected long-run cost per unit time over an infinite horizon. We assume Poisson arrival rates that depend on patient types, and Length of Stay distributions that depend on whether patients stay in their primary wards or not. Since the instances of realistic size of this problem are not easy to solve, we develop numerical methods based on Approximate Dynamic Programming. We illustrate the theory with numerical examples with parameters obtained by fitting to data from a tertiary referral hospital in Australia, and demonstrate the application potential of our methodology under practical considerations.
... 14 Moreover, the decreasing number of EDs and continuous increase in the number of patients needing emergency care create a serious health problem. 38,39 ED overcrowding adversely affects patients and their related factors, communities, delivery of emergency care, and healthcare delivery systems. 1 However, refining the efficiency of human resources and developing accurate measures of ED overcrowding will guarantee improvement in patient flow. 40 The emergency triage prediction model can also improve ED staff working efficacy and minimize workload intensity. ...
Purpose: Emergency department (ED) overcrowding is a significant concern in many hospitals in Saudi Arabia, resulting in long waiting times, delays in treating patients who need urgent care, and, consequently, decreased patient satisfaction. Additionally, ED overcrowding has been linked to increased nurse turnover rates. Therefore, this study aimed to assess nurses' perceived causes and effects of overcrowding in the EDs of five tertiary hospitals in Saudi Arabia. Methods: This study used a descriptive cross-sectional design. We surveyed 311 nurses working in the EDs of five tertiary hospitals in Saudi Arabia using the convenience sampling technique. The self-administered questionnaires used in the study were developed by the researchers. The study was conducted from October 16 to November 10, 2022. Consensus-Based Checklist for Reporting of Survey Studies was followed. Results: The results revealed that the primary perceived causes of ED overcrowding in five tertiary hospitals were unnecessary visits due to a lack of standard procedures (mean = 2.70; SD = 0.58) and lack of inpatients beds (mean = 2.69; SD = 0.65). The perceived effect of overcrowding was stress and burnout among nurses (mean = 2.85; SD = 0.47). The perceived causes and effects of overcrowding in the ED were found to be highly significant (p <0.001) based on Pearson correlation and Spearman's rank correlation. Conclusion: Unnecessary visits due to a lack of standard procedures lead to overcrowding. In addition, a lack of inpatient beds in the ED affects the care provided to patients seeking immediate medical attention. This may prolong patient waiting time, causing their conditions to deteriorate and prolonging hospital stay. Overcrowding leads to increased stress and burnout among nurses. The results of this study can be used to develop a comprehensive action plan to address ED overcrowding and its effects on patients, staff, and ED flow.
... A substantial share of these ED consulters present with low-acuity care needs and could potentially receive a more suitable treatment in primary care (PC) [3,4]. Concerning these cases, achieving a shift toward a more appropriate use of general practitioner (GP) care could benefit not only the patients concerned but also the entire ED care system, as crowded EDs are associated with poorer quality of care [5]. ...
Background
Emergency departments (ED) worldwide have to cope with rising patient numbers. Low-acuity consulters who could receive a more suitable treatment in primary care (PC) increase caseloads, and lack of PC attachment has been discussed as a determinant. This qualitative study explores factors that contribute to non-utilization of general practitioner (GP) care among patients with no current attachment to a GP.
Method
Qualitative semi-structured telephone interviews were conducted with 32 low-acuity ED consulters with no self-reported attachment to a GP. Participants were recruited from three EDs in the city center of Berlin, Germany. Data were analyzed by qualitative content analysis.
Results
Interviewed patients reported heterogeneous factors contributing to their PC utilization behavior and underlying views and experiences. Participants most prominently voiced a rare need for medical services, a distinct mobility behavior, and a lack of knowledge about the role of a GP and health care options. Views about and experiences with GP care that contribute to non-utilization were predominantly related to little confidence in GP care, preference for directly consulting medical specialists, and negative experiences with GP care in the past. Contrasting their reported utilization behavior, many interviewees still recognized the advantages of GP care continuity.
Conclusion
Understanding reasons of low-acuity ED patients for GP non-utilization can play an important role in the design and implementation of patient-centered care interventions for PC integration. Increasing GP utilization, continuity of care and health literacy might have positive effects on patient decision-making in acute situations and in turn decrease ED burden.
Trial registration
German Clinical Trials Register: DRKS00023480; date: 2020/11/27.
... In the event that blockages develop in the flow, there will be a rise in waiting times and throughput, both of which will affect the service's overall quality of delivery (Abdelrahman et al., 2015).To meet the following objectives: For all intents and purposes, the emergency room was overcrowded, tense, and hazardous, as well as having overworked staff and delayed regular activities, causing patients to be classified as outliers and for the clinical results to worsen. Increased investment in ambulatory care services, clinical decision units, and labs and endoscopic units contributed to the rise in ambulatory care, clinical decision units, and other facilities (Carter et al., 2014). The findings of the study by Kreindler, et al. (2017) indicate that although some widely established flow approaches have been repackaged and bundled into organizational improvement methodologies, the data supporting these methods is lacking. ...
... 14 Moreover, the decreasing number of EDs and continuous increase in the number of patients needing emergency care create a serious health problem. 38,39 ED overcrowding adversely affects patients and their related factors, communities, delivery of emergency care, and healthcare delivery systems. 1 However, refining the efficiency of human resources and developing accurate measures of ED overcrowding will guarantee improvement in patient flow. 40 The emergency triage prediction model can also improve ED staff working efficacy and minimize workload intensity. ...
Purpose
Emergency department (ED) overcrowding is a significant concern in many hospitals in Saudi Arabia, resulting in long waiting times, delays in treating patients who need urgent care, and, consequently, decreased patient satisfaction. Additionally, ED overcrowding has been linked to increased nurse turnover rates. Therefore, this study aimed to assess nurses’ perceived causes and effects of overcrowding in the EDs of five tertiary hospitals in Saudi Arabia.
Methods
This study used a descriptive cross-sectional design. We surveyed 311 nurses working in the EDs of five tertiary hospitals in Saudi Arabia using the convenience sampling technique. The self-administered questionnaires used in the study were developed by the researchers. The study was conducted from October 16 to November 10, 2022. Consensus-Based Checklist for Reporting of Survey Studies was followed.
Results
The results revealed that the primary perceived causes of ED overcrowding in five tertiary hospitals were unnecessary visits due to a lack of standard procedures (mean = 2.70; SD = 0.58) and lack of inpatients beds (mean = 2.69; SD = 0.65). The perceived effect of overcrowding was stress and burnout among nurses (mean = 2.85; SD = 0.47). The perceived causes and effects of overcrowding in the ED were found to be highly significant (p <0.001) based on Pearson correlation and Spearman’s rank correlation.
Conclusion
Unnecessary visits due to a lack of standard procedures lead to overcrowding. In addition, a lack of inpatient beds in the ED affects the care provided to patients seeking immediate medical attention. This may prolong patient waiting time, causing their conditions to deteriorate and prolonging hospital stay. Overcrowding leads to increased stress and burnout among nurses. The results of this study can be used to develop a comprehensive action plan to address ED overcrowding and its effects on patients, staff, and ED flow.
... Increasing numbers of ED presentations paired with limited bed capacity can result in longer waiting times and prolonged ED length of stay (LOS). Overcrowding and access block (delay in transferring the person to an admitted hospital ward bed) in the ED have become more common, and are associated with increased medical errors [6,7], poor patient experiences [8] and poorer outcomes [9,10] including death [11]. Negative ED outcomes and an inability to influence change may contribute to staff burnout [12,13]. ...
Background
The aim of this systematic review was to examine the relationship between strategies to improve care delivery for older adults in ED and evaluation measures of patient outcomes, patient experience, staff experience, and system performance.
Methods
A systematic review of English language studies published since inception to December 2022, available from CINAHL, Embase, Medline, and Scopus was conducted. Studies were reviewed by pairs of independent reviewers and included if they met the following criteria: participant mean age of ≥ 65 years; ED setting or directly influenced provision of care in the ED; reported on improvement interventions and strategies; reported patient outcomes, patient experience, staff experience, or system performance. The methodological quality of the studies was assessed by pairs of independent reviewers using The Joanna Briggs Institute critical appraisal tools. Data were synthesised using a hermeneutic approach.
Results
Seventy-six studies were included in the review, incorporating strategies for comprehensive assessment and multi-faceted care (n = 32), targeted care such as management of falls risk, functional decline, or pain management (n = 27), medication safety (n = 5), and trauma care (n = 12). We found a misalignment between comprehensive care delivered in ED for older adults and ED performance measures oriented to rapid assessment and referral. Eight (10.4%) studies reported patient experience and five (6.5%) reported staff experience.
Conclusion
It is crucial that future strategies to improve care delivery in ED align the needs of older adults with the purpose of the ED system to ensure sustainable improvement effort and critical functioning of the ED as an interdependent component of the health system. Staff and patient input at the design stage may advance prioritisation of higher-impact interventions aligned with the pace of change and illuminate experience measures. More consistent reporting of interventions would inform important contextual factors and allow for replication.
... They provide a critical link between primary care (i.e., care provided by general practitioners in the community) and hospital acute care and differentiated services (McCusker et al., 2001). Due to their complexity and high degree of connectedness with other departments, EDs are affected by the constantly changing dynamics of resources and constraints of other hospital subsystems leading to impaired patient flow through the ED, and poor patient outcomes (Carter et al., 2014;Morley et al., 2018;Naikar, 2016;Naikar et al., 2005). In response to changing constraints that threaten performance and care delivery, clinicians (e.g., nurses, medical officers, allied health) and non-clinical staff (administration staff, patient support services) often improvise and problem-solve to move patients along their ED journey quickly and safely. ...
... However, the capacity of the emergency healthcare systems has not been well developed to respond to such high demand, because creating a balance between emergency services and the required resources is challenging [10]. Hospitals need to address interventions and policies to address this significant problem [11]. ED crowding was not independently associated with mortality (odds ratio (OR) 0.94, 95% confidence interval), but tended to be associated with a higher incidence of hospital-acquired pneumonia [12]. ...
This study aims to investigate and address the issue of emergency department (ED) overcrowding, a significant problem worldwide. The study seeks to understand the impacts of ED overcrowding on emergency medical healthcare services and patient outcomes. This systematic review follows the PRISMA flow diagram and the guidelines of the Cochrane Handbook. We systematically reviewed the causes and solutions of emergency department overcrowding. We went through Google Scholar, the National Center for Biotechnology Information, the British Medical Journal, Science Direct, Ovid, Cochrane, the Saudi Journal of Emergency Medicine, Medline, and PubMed as databases. Our criteria were articles done in Saudi Arabia from 2012 to 2022. One hundred and ninety-six (196) research papers were extracted; only 28 articles met our paper inclusion-exclusion criteria. The result of these papers regarding causes, consequences, and solutions was that non-urgent and returned visits lacked knowledge of PHC, triad, and telemedicine services. Prolonged LOS is due to slow bed turnover, laboratory and consultation time, and physical response to the final decision resulting in burnout staff, wrong diagnoses, and management plans. The crowding issues can be resolved by awareness, PHC access, triad systems, and technological and telemedicine services. High demand for emergency treatment should not be a hindrance to quality treatment. Physical, technological, and strategic measures should be put in place to fight the crowding problem in EDs in Saudi Arabia, as it may cause adverse effects such as transmission of diseases and death of patients.
... A key performance indicator (KPI) for emergency department (ED) visits is the length of stay (LOS; measured in minutes) from admission to the ED until the final disposition of the visit (1). Although measuring quality in EDs presents unique challenges, numerous studies suggest that the LOS is one of the central predictors for measuring outcomes (2)(3)(4). The importance of this indicator is that previous studies have shown that the LOS for a patient in the ED is associated with the outcome of the case, including mortality and hospital admission rates (5). ...
Background
Emergency department length of stay is a vital performance indicator for quality and efficiency in healthcare. This research aimed to evaluate the length of stay patterns in emergency departments across Saudi Arabia and to identify predictors for extended stays. The study used secondary data from the Ministry of Health’s Ada’a program.
Methods
Using a retrospective approach, the study examined data from the Ada’a program on emergency department length of stay from September 2019 to December 2021. These data covered 1,572,296 emergency department visits from all regions of Saudi Arabia. Variables analyzed included quality indicators, year of visit, shift time, hospital type, and data entry method. The analysis was conducted using multiple linear regression.
Results
The study found that the median length of stay was 61 min, with significant differences among related predictors. All associations were significant with a value of p of less than 0.001. Compared to 2019, the length of stay was notably shorter by 28.5% in 2020 and by 44.2% in 2021. Evening and night shifts had a shorter length of stay by 5.9 and 7.8%, respectively, compared to the morning shift. Length of stay was lower in winter, summer, and fall compared to spring. Patients in levels I and II of the Canadian Triage and Acuity Scales had longer stays than those in level III, with those in level I reaching an increase of 20.5% in length of stay. Clustered hospitals had a longer length of stay compared to the non-clustered ones. Pediatric hospitals had a 15.3% shorter stay compared to general hospitals. Hospitals with data entered automatically had a 14.0% longer length of stay than those entered manually. Patients admitted to the hospital had a considerably longer length of stay, which was 54.7% longer compared to non-admitted patients. Deceased patients had a 20.5% longer length of stay than patients discharged alive.
Conclusion
Data at the national level identified several predictors of prolonged emergency department length of stay in Saudi Arabia, including shift time, season, severity level, and hospital type. These results underline the necessity of continuous monitoring and improvement efforts in emergency departments, in line with policy initiatives aiming to enhance patient outcomes in Saudi Arabia.
... A longer recovery time could lead to longer length of stay in the ED and ED crowding, which is associated with mortality and a higher rate of individuals who leave without being seen in the ED. 13 Therefore, the effectiveness of capnography on the recovery time of patients receiving PSA in EDs must be evaluated. The present study analyzed PSA registry data with the aim of investigating the association of capnography with shortening of recovery time after PSA. ...
Aim
Capnography is recommended for use in procedural sedation and analgesia (PSA); however, limited studies assess its impact on recovery time. We investigated the association between capnography and the recovery time of PSA in the emergency department (ED).
Methods
This study was a secondary analysis of a multicenter PSA patient registry including eight hospitals in Japan. We included all patients who received PSA in the ED between May 2017 and May 2021 and divided the patients into capnography and no‐capnography groups. The primary outcome was recovery time, defined as the time from the end of the procedure to the cessation of monitoring. The log‐rank test and multivariable analysis using clustering for institutions were performed.
Results
Of the 1265 screened patients, 943 patients who received PSA were enrolled and categorized into the capnography ( n = 150, 16%) and no‐capnography ( n = 793, 84%) groups. The median recovery time was 40 (interquartile range [IQR]: 25–63) min in the capnography group and 30 (IQR: 14–55) min in the no‐capnography group. In the log‐rank test, the recovery time was significantly longer in the capnography group ( p = 0.03) than in the no‐capnography group. In the multivariable analysis, recovery time did not differ between the two groups (adjusted hazard ratio, 0.95; 95% confidence interval, 0.77–1.17; p = 0.61).
Conclusion
In this secondary analysis of the multicenter registry of PSA in Japan, capnography use did not associate with shorter recovery time in the ED.
... The significant growth in Emergency Department (ED) attendances is an international public health issue posing a major risk to population health [1]. ED crowding affects the quality and safety of patient care and the association with a higher risk of adverse outcomes [2,3] and increased mortality rates are well-documented [4,5]. As conceptualised within the Input-Throughput-Output model [6], the causes and consequences of ED crowding are complex and multifaceted [7]. ...
Background
Innovations in models of care for older adults living with frailty presenting to the emergency department (ED) have become a key priority for clinicians, researchers and policymakers due to the deleterious outcomes older adults experience due to prolonged exposure to such an environment. This study aimed to develop a set of expert consensus-based statements underpinning operational design, outcome measurement and evaluation of a Frailty at the Front Door (FFD) model of care for older adults within an Irish context.
Methods
A modified real-time Delphi method was used. Facilitation of World Café focus groups with an expert panel of 86 members and seperate advisory groups with a Public and Patient Involvement panel of older adults and members of the Irish Association of Emergency Medicine generated a series of statements on the core elements of the FFD model of care. Statements were analysed thematically and incorporated into a real-time Delphi survey, which was emailed to members of the expert panel. Members were asked to rank 70 statements across nine domains using a 9-point Likert scale. Consensus criteria were defined a priori and guided by previous research using 9-point rating scales.
Results
Fifty members responded to the survey representing an overall response rate of 58%. Following analyses of the survey responses, the research team reviewed statements for content overlap and refined a final list of statements across the following domains: aims and objectives of the FFD model of care; target population; screening and assessment; interventions; technology; integration of care; evaluation and metrics; and research.
Conclusion
Development of a consensus derived FFD model of care represents an important step in generating national standards, implementation of a service model as intended and enhances opportunities for scientific impact. Future research should focus on the development of a core outcome set for studies involving older adults in the ED.
... In a broader context, excessive overcrowding leads to adverse repercussions on patient well-being, mortality rates, disease incidence, patient contentment, and the overall standard of healthcare provision [6,13,14]. Additionally, it gives rise to prolonged durations of stay within the ED, heightened instances of patients departing without receiving attention, and an elevated frequency of medical inaccuracies [15,16]. ...
Background
The escalating overload and saturation of emergency services, primarily caused by non-urgent cases overwhelming the system, have spurred a critical necessity for innovative solutions that can effectively differentiate genuine emergencies from situations that could be managed through alternative means, such as using AI chatbots. This study aims to evaluate and compare the accuracy in differentiating between a medical emergency and a non-emergency of three of the most popular AI chatbots at the moment.
Methods
In this study, patient questions from the online forum r/AskDocs on Reddit were collected to determine whether their clinical cases were emergencies. A total of 176 questions were reviewed by the authors, with 75 deemed emergencies and 101 non-emergencies. These questions were then posed to AI chatbots, including ChatGPT, Google Bard, and Microsoft Bing AI, with their responses evaluated against each other and the authors’ responses. A criteria-based system categorized the AI chatbot answers as “yes,” “no,” or “cannot determine.” The performance of each AI chatbot was compared in both emergency and non-emergency cases, and statistical analysis was conducted to assess the significance of differences in their performance.
Results
In general, AI chatbots considered around 12-15% more cases to be an emergency than reviewers, while they considered a very low number of cases as non-emergency compared to reviewers (around 35% fewer cases). Google Bard detected the most true emergency cases (87%) and true non-emergency cases (36%). However, no real difference in performance between the three AI chatbots was found in detecting true emergencies (p-value = 0.35) and non-emergency cases (p-value = 0.16).
Conclusions
These AI systems require further refinement to identify emergency situations accurately, but they could potentially be an innovative tool for emergency care and improving patient outcomes. The integration of AI chatbots like ChatGPT, Google Bard, and Microsoft Bing Chat offers a promising avenue to mitigate ED strain and enhance emergency management.
... The ED provides "rapid, high quality, continuously accessible, unscheduled care" for a wide range of acute illnesses and injuries and illnesses [3] but the primary purpose of the ED is to treat patients with potentially life-threatening illnesses and injuries. Therefore, ED crowding is a significant patient safety issue associated with increased morbidity and mortality [4]. The causes of ED crowding are multifactorial and relate to input, throughout and output factors. ...
Background
Utilisation of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing inappropriate or avoidable attendances is an important area for intervention in prevention of ED crowding. This study aims to develop a consensus between clinicians across care settings about the “appropriateness” of attendances to the ED in Ireland.
Methods
The Better Data, Better Planning study was a multi-centre, cross-sectional study investigating factors influencing ED utilisation in Ireland. Data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels.
Results
The National Panel determined that 11% (GP) to 38% (EMC) of n = 306 lower acuity presentations could be treated by a GP within 24-48 h (k = 0.259; p < 0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered “inappropriate” (k = 0.341; p < 0.001). For attendances deemed “appropriate” the admission rate was 47% compared to 0% for “inappropriate” attendees. There was no consensus on 45% of charts (n = 136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0 to 59% and for inappropriate attendances ranged from 0 to 29%. For the Local Panel review (n = 306) consensus on appropriateness ranged from 40 to 76% across ED sites.
Conclusions
Multidisciplinary clinicians agree that “inappropriate” use of the ED in Ireland is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogenous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.
... It contributes to Emergency Department (ED) crowding, bed access block, and increased length of stay (LOS), all of which pose substantial risks to patient safety [3,4]. Indeed, the risk of inpatient mortality for patients admitted via the ED during crowded periods can also be as much as 34% higher compared to those admitted during non-crowded periods [5]. The impact of poor patient flow is also felt throughout hospitals more broadly, in the form of a decreased quality of care for admitted patients [6], and reduced financial performance [7] among other factors. ...
Background: Poor patient flow can lead to adverse outcomes for patients and organisational inefficiency. Many hospitals have addressed suboptimal patient flow by increasing resourcing, such as bed stock and staffing, however, this is an unsustainable approach. In determining the nature of poor patient flow issues, it is important to collect data from healthcare professionals who manage patient flow on a daily basis. Doing so provides insights into the current state of patient flow management in its entirety, whilst also helping with the development of sustainable solutions.; Methods: Thirteen semi-structured interviews were conducted with clinicians who were directly involved with patient flow at a tertiary care centre in Tasmania, Australia. Results: Through a thematic analysis method, four major themes were developed: managing patient flow, communication for decisions, tools as enablers and barriers and increasing complexity. Conclusions: The findings of this study provide great insights into patient flow issues, with potential solutions identified to address them.
... [5][6][7] Some authors suggested that disappointment with these expectations reduces patient satisfaction and the likelihood of sticking to treatment, returning to appointments, or cooperating. [8][9] Patient delay in receiving health care reduces the inflow of support and affects public health services. This might lead to an increase in the uptake of care from unorthodox or unconventional treatment sources such as public pharmacies, drug vendors, herbal medicine traders, religious or spiritual institutions, and students in health-related disciplines. ...
Background: Health-seeking behaviour is defined as the behaviour of people who malfunction or feel sick to find a suitable treatment. One of the critical factors influencing health-seeking behaviour is the satisfaction obtained from healthcare services, which is often linked to the quality of the service received.
Objective: To assess university students' health-seeking behaviour and perception of healthcare services provided at the Babcock University Teaching Hospital, Ilishan-Remo, Nigeria.
Methods: A descriptive, cross-sectional study of 425 undergraduate students of Babcock University was conducted using a validated structured questionnaire. The socio-demographic characteristics, health-seeking behaviour and perception of available services were analysed using descriptive statistics.
Results: About half of the respondents (50.6%) had poor health-seeking behaviour, and most (68.5%) had a positive perception of the healthcare services rendered by the institution’s healthcare facility. Some factors that affected healthcare-seeking behaviour included the non-availability of medications (37.2%), the attitude of healthcare workers (32.5%), and the cost of care (13.6%).
Conclusion: The study demonstrated good health-seeking behaviour and a positive perception of the available healthcare services. However, the factors associated with poor health-seeking behaviour included unavailable medications and the poor attitude of healthcare workers. Regular appraisal and pharmacy restocking should be done to ensure an up-to-date supply of commonly prescribed medications.
... The ED provides "rapid, high quality, continuously accessible, unscheduled care" for a wide range of acute illnesses and injuries and illnesses [3] but the primary purpose of the ED is to treat patients with potentially life-threatening illnesses and injuries. Therefore, ED crowding is a signi cant patient safety issue associated with increased morbidity and mortality [4]. The causes of ED crowding are multifactorial and relate to input, throughout and output factors. ...
Introduction: Utilization of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing avoidable attendance is an important area for intervention in the prevention of ED crowding. This study aims to develop a consensus among clinicians across care settings about the “appropriateness” of attendance at the ED in Ireland.
Method: The Better Data, Better Planning study was a multi-center, cross-sectional study investigating factors influencing ED utilization in Ireland. Following ethical approval, data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels.
Results: The National Panel determined that 11% (GP) to 38% (EMC) of n=306 lower acuity presentations could be treated by a GP within 24-48h (k=0.259; p<0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered “inappropriate” (k=0.341; p<0.001). For attendances deemed “appropriate” the admission rate was 47% compared to 0% for “inappropriate” attendees. There was no consensus on 45% of charts (n=136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0-59% and for inappropriate attendances ranged from 0-29%. For the Local Panel review (n=306) consensus on appropriateness ranged from 40-76% across sites.
Conclusion: Multidisciplinary clinicians agree that “inappropriate” use of Irish EDs is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogeneous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.
... For example, in the emergency department, where a strong patient-nurse relationship is not formed and the communication period is short, maybe NFE which was not significant in this study, becomes doubly important because the patients in this department experience intense negative emotions at the moment. Maybe a natural and real excitement in the nurse of this department can be very effective in the formation of the relationship and on the other hand positive feedback from the environment and bring higher job satisfaction (Carter et al., 2014;Mirzaei et al., 2022). Furthermore, for a nurse who works in the psychiatric department of a hospital and is faced with an exaggerated flow of extreme positive and negative emotions of patients every day, SA may be a more suitable emotional reaction and bring more job satisfaction (Cramer et al., 2020;Young and Hee, 2022). ...
Emotional labor is considered an important part of the role in the nursing field. Previous studies have found inconsistencies between emotional labor and job satisfaction of nurses, this is due to the relationship between them being affected by other factors. However, the current nurse-patient relationship is tense and leads to an unsafe and unstable working environment for nurses. It has yet to be confirmed whether the nurse-patient relationship can be used as a mediating variable to further explain the association that exists between emotional labor and job satisfaction. Therefore, this study tested the mediating effect of the nurse-patient relationship between emotional labor and job satisfaction among Chinese nurses. A total of 496 nurses were included in the study. Data collection was from December 2021 to March 2022 using the convenience sampling method. SPSS 26.0 and AMOS 23.0 software were used to perform structural equation modeling and analyze the relationship between variables. The results showed surface acting negatively affected nurse-patient relationships and job satisfaction, contrary to deep acting and naturally felt emotions. The parallel mediation of nurse-patient trust and patient-centered nursing in the relationship between emotional labor and job satisfaction was found to be statistically significant. Our study highlighted the important mediation of nurse-patient trust and the importance of the positive effects of emotional labor. Future studies can use these findings as a reference to develop interventions.
... The major consequences of ED delays among patients are decreasing patient satisfaction, declining quality of care, and increasing complications and, ultimately, mortality [4,5]. The reasons for delays typically include demographic changes, comorbidity, complexity, and increasing numbers of walk-in patients [6] as well as referred and transferred patients, particularly in tertiary or reference centres [7]. ...
Background:
Optimal throughput times in emergency departments can be adjudicated by emergency physicians. Emergency physicians can also define causes of delays during work-up, such as waiting for imaging, clinical chemistry, consultations, or exit blocks. For adequate streaming, the identification of predictors of delays is important, as the attribution of resources depends on acuity, resources, and expected throughput times.
Objective:
This observational study aimed to identify the causes, predictors, and outcomes of emergency physician-adjudicated throughput delays.
Methods:
Two prospective emergency department cohorts from January to February 2017 and from March to May 2019 around the clock in a tertiary care centre in Switzerland were investigated. All consenting patients were included. Delay was defined as the subjective adjudication of the responsible emergency physician regarding delay during emergency department work-up. Emergency physicians were interviewed for the occurrence and cause of delays. Baseline demographics, predictor values, and outcomes were recorded. The primary outcome - delay - was presented using descriptive statistics. Univariable and multivariable logistic regression analyses were performed to assess the associations between possible predictors and delays and hospitalization, intensive care, and death with delay.
Results:
In 3656 (37.3%) of 9818 patients, delays were adjudicated. The patients with delays were older (59 years, interquartile range [IQR]: 39-76 years vs 49 years, IQR: 33-68 years) and more likely had impaired mobility, nonspecific complaints (weakness or fatigue), and frailty than the patients without delays. The main causes of delays were resident work-up (20.4%), consultations (20.2%), and imaging (19.4%). The predictors of delays were an Emergency Severity Index of 2 or 3 at triage (odds ratio [OR]: 3.00; confidence interval [CI]: 2.21-4.16; OR: 3.25; CI: 2.40-4.48), nonspecific complaints (OR: 1.70; CI: 1.41-2.04), and consultation and imaging (OR: 2.89; CI: 2.62-3.19). The patients with delays had an increased risk for admission (OR: 1.56; CI: 1.41-1.73) but not for mortality than those without delays.
Conclusion:
At triage, simple predictors such as age, immobility, nonspecific complaints, and frailty may help to identify patients at risk of delay, with the main reasons being resident work-up, imaging, and consultations. This hypothesis-generating observation will allow the design of studies aimed at the identification and elimination of possible throughput obstacles.
... This absence of regulation is frequently discussed in the context of ED overcrowding, which is potentially disruptive to effective care and could contributive to adverse outcomes. 15 There is no obligation to register with a practice to receive GP care, and patients are free to choose or change providers anytime. While, in a recent representative survey of the adult German population, 90% of respondents from urban areas reported attachment to a GP, 16 it is unclear to which extent this actually influences consultation decisions of acute illness. ...
Objectives
Low-acuity patients presenting to emergency departments (EDs) frequently have unmet ambulatory care needs. This qualitative study explores the patients’ views of an intervention aimed at education about care options and promoting primary care (PC) attachment.
Design
Qualitative telephone interviews were conducted with a subsample of participants of an interventional pilot study, based on a semi-structured interview guide. The data were analysed through qualitative content analysis.
Setting
The study was carried out in three EDs in the city centre of Berlin, Germany.
Participants
Thirty-two low-acuity ED consulters with no connection to a general practitioner (GP) who had participated in the pilot study were interviewed; (f/m: 15/17; mean age: 32.9 years).
Intervention
In the pilot intervention, ED patients with low-acuity complaints were provided with an information leaflet on appropriate ED usage and alternative care paths and they were offered an optional GP appointment scheduling service. Qualitative interviews explored the views of a subsample of the participants on the intervention.
Results
Interviewees perceived both parts of the intervention as valuable. Receiving a leaflet about appropriate ED use and alternatives to the ED was viewed as helpful, with participants expressing the desire for additional online information and a wider distribution of the content. The GP appointment service was positively assessed by the participants who had made use of this offer and seen as potentially helpful in establishing a long-term connection to GP care. The majority of patients declining a scheduled GP appointment expected no personal need for further medical care in the near future or preferred to choose a GP independently.
Conclusions
Low-acuity ED patients seem receptive to information on alternative acute care options and prevailingly appreciate measures to encourage and facilitate attachment to a GP. Promoting PC integration could contribute to a change in future usage behaviour.
Trial registration number
DRKS00023480.
... Te high turnout of patients to the emergency department is overburdening healthcare providers and the systems which put them at risk because of overcrowding [1][2][3][4]. Managing outfow to the emergency department is the main goal to maintain the high quality of care and to ensure patient safety and satisfaction [5]. Te scope of care provided in the emergency department varies depending on the patient's condition and severity that ranged from immediate to minimal or nonurgent. ...
Background:
Due to significant emergency department overcrowding, some hospitals implemented a system of directing certain patients who were deemed not in need of emergency care to other facilities called triage away. Pathways were developed as ways to stream patient from emergency departments to primary healthcare who is presenting with less urgent or nonurgent conditions. Thus, the purpose of this study was to explore the pathways (process) for streaming patients from emergency department to primary healthcare at three different sites across Western Region of Saudi Arabia and to identify the streaming criteria and guidance.
Materials and methods:
This study used a qualitative observational design. Data were collected through an unstructured observational approach, with an in-depth case study observation involving three emergency departments in the Western Region. Data were collected over three months until data saturated and recorded in the form of filed notes.
Results:
The results of this study explored that all CTAS-5 were streamed away either (off-site) or (on-site) from emergency department. The average of the sorting/triage cases were around 200 to 250 per shift, and about third to half of them were streamed to Primary Health Centre or Urgent Care Clinic. The total streamed patients were ranging from 50 to 60 per shift, which mean 15-20 case per hour. The study highlighted many factors that influence the practice and decision of streaming.
Conclusions:
In general, the term "streaming" was not as widely known among emergency clinicians, as was the term "triage." However, streaming was performed as an evidence-based practice, and clinicians routinely acted to direct patients based on hospital policies. Although, in one hospital, some nurses hack the system to manage the flow of patients based on their intuition. In contrast, the nurses in another hospital emphasised the importance of experience and confidence in streaming improvement.
... Contacts to out-of-hours (OOH) healthcare services are increasing globally and contribute to emergency department (ED) crowding, which has a negative impact on patient safety [1,2]. Call centers are used to optimize the use of acute OOH services by gatekeeping and triage of callers instead of self-referrals, and may further support the callers by providing advice on selfcare [3]. ...
Background:
Young children are among the most frequent patients at medical call centers, even though they are rarely severely ill. Respiratory tract symptoms are among the most prevalent reasons for contact in pediatric calls. Triage of children without visual cues and through second-hand information is perceived as difficult, with risks of over- and under-triage.
Objective:
To study the safety and feasibility of introducing video triage of young children with respiratory symptoms at the medical helpline 1813 (MH1813) in Copenhagen, Denmark, as well as impact on patient outcome.
Methods:
Prospective quality improvement study including 617 patients enrolled to video or standard telephone triage (1:1) from February 2019-March 2020. Data originated from MH1813 patient records, survey responses, and hospital charts. Primary outcome was difference in patients staying at home eight hours after the call. Secondary outcomes weas hospital outcome, feasibility and acceptability. Adverse events (intensive care unit admittance, lasting injuries, death) were registered. Logistic regression was used to test the effect on outcomes. The COVID-19 pandemic shut the study down prematurely.
Results:
In total, 54% of the included patients were video-triaged., and 63% of video triaged patients and 58% of telephone triaged patients were triaged to stay at home, (p = 0.19). Within eight and 24 hours, there was a tendency of fewer video-triaged patients being assessed at hospitals: 39% versus 46% (p = 0.07) and 41% versus 49% (p = 0.07), respectively. At 24 hours after the call, 2.8% of the patients were hospitalized for at least 12 hours. Video triage was highly feasible and acceptable (>90%) and no adverse events were registered.
Conclusion:
Video triage of young children with respiratory symptoms at a medical call center was safe and feasible. Only about 3% of all children needed hospitalization for at least 12 hours. Video triage may optimize hospital referrals and increase health care accessibility.
... [2][3][4][5][6] Prolonged waits are associated with higher risks of mortality, hospital admission, 30-day readmission, patient dissatisfaction, and costs. 7,8 Emergency department triage, or the sorting of patients based on predicted acuity and resource needs, is necessary to ensure patients who require immediate care are treated first. The triage system used in over 70% of EDs across the US, 9 the Emergency Severity Index (ESI), was developed in 1999. ...
Importance:
Accurate emergency department (ED) triage is essential to prioritize the most critically ill patients and distribute resources appropriately. The most used triage system in the US is the Emergency Severity Index (ESI).
Objectives:
To derive and validate an algorithm to assess the rate of mistriage and to identify characteristics associated with mistriage.
Design, setting, and participants:
This retrospective cohort study created operational definitions for each ESI level that use ED visit electronic health record data to classify encounters as undertriaged, overtriaged, or correctly triaged. These definitions were applied to a retrospective cohort to assess variation in triage accuracy by facility and patient characteristics in 21 EDs within the Kaiser Permanente Northern California (KPNC) health care system. All ED encounters by patients 18 years and older between January 1, 2016, and December 31, 2020, were assessed for eligibility. Encounters with missing ESI or incomplete ED time variables and patients who left against medical advice or without being seen were excluded. Data were analyzed between January 1, 2021, and November 30, 2022.
Exposures:
Assigned ESI level.
Main outcomes and measures:
Rate of undertriage and overtriage by assigned ESI level based on a mistriage algorithm and patient and visit characteristics associated with undertriage and overtriage.
Results:
A total of 5 315 176 ED encounters were included. The mean (SD) patient age was 52 (21) years; 44.3% of patients were men and 55.7% were women. In terms of race and ethnicity, 11.1% of participants were Asian, 15.1% were Black, 21.4% were Hispanic, 44.0% were non-Hispanic White, and 8.5% were of other (includes American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and multiple races or ethnicities), unknown, or missing race or ethnicity. Mistriage occurred in 1 713 260 encounters (32.2%), of which 176 131 (3.3%) were undertriaged and 1 537 129 (28.9%) were overtriaged. The sensitivity of ESI to identify a patient with high-acuity illness (correctly assigning ESI I or II among patients who had a life-stabilizing intervention) was 65.9%. In adjusted analyses, Black patients had a 4.6% (95% CI, 4.3%-4.9%) greater relative risk of overtriage and an 18.5% (95% CI, 16.9%-20.0%) greater relative risk of undertriage compared with White patients, while Black male patients had a 9.9% (95% CI, 9.8%-10.0%) greater relative risk of overtriage and a 41.0% (95% CI, 40.0%-41.9%) greater relative risk of undertriage compared with White female patients. High relative risk of undertriage was found among patients taking high-risk medications (30.3% [95% CI, 28.3%-32.4%]) and those with a greater comorbidity burden (22.4% [95% CI, 20.1%-24.4%]) and recent intensive care unit utilization (36.7% [95% CI, 30.5%-41.4%]).
Conclusions and relevance:
In this retrospective cohort study of over 5 million ED encounters, mistriage with ESI was common. Quality improvement should focus on limiting critical undertriage, optimizing resource allocation by patient need, and promoting equity.
... The emergency department is the point of contact of many people with a medical system, which is one of the most hectic parts of the hospitals. 1 Workplace violence means any situations or incidents in which personnel are subjected to verbal or physical threats due to the situations in their jobs. 2 Job satisfaction of the Health staff and safety feeling at workplace are important issues. ...
Objectives: The Emergency Department (ED) is one of the most important places in a hospital in which patients are full of pain and stress because of its hectic nature. Consequently, there are a lot of quarrels and fights in the emergency department. This study intends to assess the effect of exhibition of educational messages as a way to decrease the violence in the Emergency Room (ER). Methods: We conducted a cross-sectional prospective survey at the Emergency Room (ER) of Shariati hospital of Tehran in September 2016. Data collection was carried out via distributing a qualitative questionnaire among the Emergency Department (ED) staff at baseline and 3 months after the educational intervention. We measured the total and mean number of various types of violence per survey. We utilized SPSS software version 16 in analysis of data using Mann-Whitney Test. Results: The analysis showed 47.5% verbal violence before the intervention vs 60% after that (p-value=0.598), 20.8% financial violence pre-intervention versus 43.8% post intervention (p-value=0.253), both of which were not significant statistically; however, physical violence considerably decreased from 83.9% to 47.6% during the study (p-value=0.01). During the semi-structured interviews with personnel, it was found that this presentation had some positive effects on controlling the stress of the environment practically, although it did not appear in the analysis. Conclusion: This type of public education in the hospital does not seem to be independently effective in reducing the violence in the Emergency Room (ER). According to the results, most violence indexes, except Physical violence, have not been mitigated after the intervention significantly. Perhaps, it could be more efficient by using audiovisual media, animation, and other captivating methods.
Introduction: Biological Events affect large populations depending on transmission potential and propagation. A recent example of a biological event spreading globally is the COVID-19 pandemic, which has had severe effects on the economy, society, and even politics ,in addition to its broad occurrence and fatalities.
The aim of this systematic scoping review was to look into patient flow management techniques and approaches used globally in biological incidents.
Methods: The current investigation was conducted based on the guidelines of PRISMA for Scoping Review ,which is also used for systematic review and meta-analysis studies. All articles released until March 31, 2023, were examined for this study, regardless of the year of publication. The authores were searched in databases including Scopus, Web of Science, PubMed and Google scholar search engine. Papers with subjects and keywords about patient flow management and patient management policies during epidemics were included in the inclusion criteria, while all non-English language publications including those with only English abstracts were excluded.
Results: A total of 19231 articles were included in this study and after screening, 36 articles were eventually entered into the final analysis. 84 primary categories and subcategories were identified from the review of pertinent studies. To facilitate more precise analysis and understanding, factors were categorised into seven categories: patient flow simulation models, risk communication management, integrated ICT system establishment, collaborative interdisciplinary and intersectoral approach, systematic patient management, promotion of health information technology models, modification of triage strategies, and optimal resource and capacity management.
Conclusion: Patient flow management during biological Events plays a crucial role in maintaining the performance of the healthcare system. When public health-threatening biological incidents occur, due to the high number of patients, it is essential to implement a holistic ,and integrated approach from rapid identification to treatment and discharge of patients.
Background
Emergency department (ED) crowding has repercussions on acute care, contributing to prolonged wait times, length of stay, and left without being seen (LWBS). These indicators are regarded as systemic shortcomings, reflecting a failure to provide equitable and accessible acute care. The objective was to evaluate the effectiveness of interventions aimed at improving ED care delivery indicators.
Methods
This was a systematic review and meta‐analysis of randomized controlled trials (RCTs) assessing ED interventions aimed at reducing key metrics of time to provider (TTP), time to disposition (TTD), and LWBS. We excluded disease‐specific trials (e.g., stroke). We used Cochrane's revised tool to assess the risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations to rate the quality of evidence. The meta‐analysis was performed using a random‐effects model and Cochrane Q test for heterogeneity. Data were summarized as means (±SD) for continuous variables and risk ratios (RR) with 95% confidence intervals (CIs).
Results
We searched MEDLINE, EMBASE, and other major databases. A total of 1850 references were scanned and 20 RCTs were selected for inclusion. The trials reported at least one of the three outcomes of TTD, TTP, or LWBS. Most interventions focused on triage liaison physician and point‐of‐care (POC) testing. Others included upfront expedited workup (ordering tests before full evaluation by a provider), scribes, triage kiosks, and sending notifications to consultants or residents. POC testing decreased TTD by an average of 5–96 min (high heterogeneity) but slightly increased TTP by a mean difference of 2 min (95% CI 0.6–4 min). Utilizing a triage liaison physician reduced TTD by 28 min (95% CI 19–37 min; moderate‐quality evidence) and was more effective in reducing LWBS than routine triage (RR 0.76, 95% CI 0.66–0.88; moderate quality).
Conclusions
Operational strategies such as POC testing and triage liaison physicians could mitigate the impact of ED crowding and appear to be effective. The current evidence supports these strategies when tailored to the appropriate practice environment.
Background
Predicting potential overcrowding is a significant tool in efficient emergency department (ED) management. Our aim was to develop and validate overcrowding predictive models using accessible and high quality information.
Methods
Retrospective cohort study of consecutive days in the Hospital Italiano de Buenos Aires ED from june 2016 to may 2018. We estimated hourly NEDOCS score for the entire period, and defined the outcome as Sustained Critical ED Overcrowding (EDOC) equal to occurrence of 8 or more hours with a NEDOCS score ≥ 180. We generated 3 logistic regression predictive models with different related outcomes: beginning, ending or occurrence of Sustained Critical EDOC. We estimated calibration and discrimination as internal (random validation group and bootstrapping) and external validation (different period and different ED).
Results
The main model included both the beginning and occurrence of NEDOCS, including weather variables, variables related to NEDOCS itself and patient flow variables. The second model considered only the beginning of Sustained Critical EDOC and included variables related to NEDOCS. The last model considered the end of Sustained Critical EDOC and it included variables related to NEDOCS, weather, bed occupancy and management. Discrimination for the main model had an area under the receiver-operator curve of 0.997 (95%CI 0.994–1) in the validation group. Calibration for the model was very high on internal validation and acceptable on external validation.
Conclusion
The Sustained Critical EDOC predictive model includes variables that are easily obtained and can be used for effective resource management in situations of overcrowding.
The COVID‐19 pandemic catapulted Telehealth to the forefront of Emergency Medicine (EM) as an alternative way of assessing and managing patients. This challenged the traditional idea that EM can only be practised within brick‐and‐mortar EDs. Many Emergency Physicians may find the idea of practising Telehealth in Emergency Medicine (TEM) confronting, particularly in the absence of training and clear practice guidelines. The purpose of the present paper is to describe the current use of TEM in Australasia, and outline the advantages and barriers in adopting this practice domain.
Background Overcrowding and long wait times in the emergency department (ED) have resulted in decreased patient satisfaction and quality of care. One of the solutions proposed to address wait times is the introduction of the nurse practitioner (NP) role in the ED. We present a systematic mixed studies review protocol that aims to gather and analyze available knowledge on the impact of the NP role in the ED on patients, other healthcare providers, and organizations. Methods The review will employ a mixed studies analysis approach. Data will be gathered from peer-reviewed and grey literature in English with no time limit. All international publications on the impact of NP role implementation that meets the inclusion criteria in the ED setting will be included. Each study will be appraised for quality using the mixed methods appraisal tool and data extracted by two independent authors. In the presence of conflict, a third author will provide a resolution. Study characteristics and findings will be synthesized using descriptive analysis, meta-analysis, and a three-stage thematic analysis approach. The review results will be presented using the PRISMA checklist for systematic reviews. Conclusions The systematic review will present current evidence on the impact of NP role implementation in the ED setting. The results are anticipated to support decisions and policymakers in their quest to decrease ED wait times and improve the quality of patient care in healthcare settings. Keywords: Nursing, Nurse Practitioner, Emergency Department, Patient Care, Systematic Review
The emergency department (ED) plays a critical role in our healthcare system, providing urgent care to patients in need. However, in recent years, there has been a crisis in the ED, with overcrowding, long wait times, and patient dissatisfaction becoming common issues. This essay explores the crisis in the emergency department, focusing on the causes, consequences, and potential solutions to address this pressing issue.
Elderly patients, when they present to the emergency department (ED) or are admitted to the hospital, are at higher risk of adverse outcomes such as higher mortality and longer hospital stays. This is mainly due to their age and their increased fragility. In order to minimize this already increased risk, adequate triage is of foremost importance for fragile geriatric (>75 years old) patients who present to the ED. The admissions of elderly patients from 1 January 2014 to 31 December 2020 were examined, taking into consideration the presence of two different triage systems, a 4-level (4LT) and a 5-level (5LT) triage system. This study analyzes the difference in wait times and under- (UT) and over-triage (OT) in geriatric and general populations with two different triage models. Another outcome of this study was the analysis of the impact of crowding and its variables on the triage system during the COVID-19 pandemic. A total of 423,257 ED presentations were included. An increase in admissions of geriatric, more fragile, and seriously ill individuals was observed, and a progressive increase in crowding was simultaneously detected. Geriatric patients, when presenting to the emergency department, are subject to the problems of UT and OT in both a 4LT system and a 5LT system. Several indicators and variables of crowding increased, with a net increase in throughput and output factors, notably the length of stay (LOS), exit block, boarding, and processing times. This in turn led to an increase in wait times and an increase in UT in the geriatric population. It has indeed been shown that an increase in crowding results in an increased risk of UT, and this is especially true for 4LT compared to 5LT systems. When observing the pandemic period, an increase in admissions of older and more serious patients was observed. However, in the pandemic period, a general reduction in waiting times was observed, as well as an increase in crowding indices and intrahospital mortality. This study demonstrates how introducing a 5LT system enables better flow and patient care in an ED. Avoiding UT of geriatric patients, however, remains a challenge in EDs.
Perceived treatment urgency of mental disorders are important as they determine utilization of health care. The aim was to analyze variations in perceived treatment urgency in cases of psychosis (adolescents), alcoholism (adults), and depression (older adults) with two levels of severity each by characteristics of the case and the respondents. A telephone survey (N = 1200) with vignettes describing cases of psychosis, alcoholism, and depression was conducted in Hamburg, Germany. Vignettes varied by symptom severity and sex. Perceived treatment urgency was assessed by three items. A sum scale was calculated. Linear regression models were computed to analyze differences in perceived urgency by characteristics of the case (severity, sex) and the respondents (sex, age, education, migration background, illness recognition, personal affliction). Perceived treatment urgency was significantly higher in severe cases and varied by education. Additionally, regarding psychosis, estimated urgency varied significantly by correct illness recognition. With regard to depression, perceived urgency differed significantly by age and correct illness recognition. Interaction effects between case severity and sociodemographic characteristics of the respondents, personal affliction, and correct recognition of the disorder were found. The identified differences should be considered in the development of interventions on mental health literacy with regard to adequate urgency assessment.
Study design /setting
Retrospective study.
Objective
To understand what patients utilize emergency departments (EDs) versus urgent care centers for low back pain (LBP).
Summary of Background Data
LBP is a common reason for ED visits. In the setting of trauma, or recent surgery, the resources of EDs may be needed. However, urgent care centers, may be appropriate for other cases.
Methods
Adult patients less than 65 years of age presenting to the ED or urgent care on the day of diagnosis of low back pain were identified from the 2019 PearlDiver M151 administrative database. Exclusion criteria included history of radiculopathy or sciatica, spinal surgery, spinal cord injury, other traumatic, neoplastic, or infectious diagnoses in the 90 days prior, or Medicare insurance. Patient age, sex, Elixhauser Comorbidity Index (ECI), geographic region, insurance, and management strategies were extracted. Factors associated with urgent care relative to ED utilization were assessed using multivariable analysis.
Results
Of 356,284 LBP patients, ED visits were identified for 345,390 (96.9%) and urgent care visits for 10,894 (3.1%). Factors associated with urgent care use relative to the ED were: geographic region (relative to Midwest; Northeast odds ratio (OR) 5.49, South OR 1.54, West OR 1.32), insurance (relative to Medicaid; Commercial OR 4.06), lower ECI (OR 1.28 per 2-point decrease), and higher age (OR 1.10 per decade), female sex (OR 1.09), and use of advanced imaging (OR 0.08) within 1 week ( P <0.001 for all).
Conclusions
Most patients presenting for a first diagnosis of isolated LBP went to the ED relative to urgent care. The greatest drivers of urgent care versus ED utilization for low back pain were insurance type and geographic region. Utilization of advanced imaging was higher among ED patients, but rates of surgical intervention were similar between those seen in the ED and urgent care.
Background
Postoperative healthcare utilization and readmissions are common among the hepatopancreatobiliary (HPB) population. We evaluated the surgical volume required to sustain advanced practice providers (APPs) in the perioperative setting for cost reduction.
Study Design
Using decision analysis modeling, we evaluated costs of employing dedicated perioperative APP Navigators compared with no APPs Navigators. Simulated subjects could: 1) present to an emergency department (ED), with or without readmission, 2) present for direct readmission, 3) require additional office visits, or 4) no additional care. We informed our model using the most current available published data and performed sensitivity analyses to evaluate thresholds under which dedicated perioperative APP Navigators are beneficial.
Results
Subjects within the APP Navigators cohort accumulated $1,270 and a readmission rate of 6.9%, compared with $2,170 and 13.5% with No APP Navigators, yielding a cost-savings of $905 and 48% relative reduction in readmission. Based on these estimated cost-savings and national salary ranges, a perioperative APPs become financially self-sustaining with 113 to 139 annual HPB cases, equating to 2 to 3 HPB cases weekly. Sensitivity analyses revealed that perioperative APP Navigators were no longer cost-saving when direct readmission rates exceeded 8.9% (base case 3.7%).
Conclusions
We show that readmissions are reduced by nearly 50% with an associated cost-savings of $900 when employing dedicated perioperative APPs. This position becomes financially self-sufficient with an annual HPB case load of 113 to 139 cases. High-volume HPB centers could benefit from post-discharge APP Navigators to optimize outcomes, minimize high-value resource utilization, and ultimately save costs.
Objective:
To benchmark blood culture (BC) quality in an Australian ED, explore groups at risk of suboptimal BC collection, and identify potential areas for improvement.
Methods:
This retrospective observational study was undertaken to benchmark quality of BCs in a tertiary adult ED in terms of number of BC sets per patient and proportion of patients with false positive (contaminated) BC results.
Results:
A single BC set was taken for 55% of patients, with lower acuity patients being more likely to have a single BC set taken. BC false positives occurred in 3.4% of presentations, with higher frequency in some critically unwell patient groups. The true positive BC rate was 10.9%, with pathogens most frequently isolated in older patients, those with a haematological condition or genitourinary source, and those admitted to inpatient wards. Hospital length of stay did not differ between patients with negative and patients with false positive BCs.
Conclusions:
BC quality standards in the ED such as false positive rate <3% and single culture rate <20% are required to facilitate benchmarking and prospective quality improvement. The sensitivity and specificity of this common and critical test can be improved. Patient subgroups associated with poor-quality BC collection can be identified and should be a focus of future work.
Background
We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design.
Objective(s), study design, settings and participants
Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions.
Results
A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important.
Forty patient/carer participants described emergency department attendances; most reported a reluctance to attend. Participants emphasised the importance of being treated with dignity, timely and accurate information provision and involvement in decision-making. Receiving care in a calm environment with attention to personal comfort and basic physical needs were key. Patient goals included diagnosis and resolution, well-planned discharge home and retaining physical function. Participants perceived many of these goals of care were not attained.
A total of 21 professional participants were interviewed and 23 participated in focus groups, largely confirming the review evidence. Implementation challenges identified included the urgent and emergency care environment, organisational approaches to service development, staff skills and resources.
Work package 2 involved 45 interviews and 30 hours of observation in four contrasting emergency departments. Key themes relating to implementation included:
intervention-related
staff: frailty mindset and behaviours
resources: workforce, space, and physical environment
operational influences: referral criteria, frailty assessment, operating hours, transport.
context-related
links with community, social and primary care
organisation and management support
COVID-19 pandemic.
approaches to implementation
service/quality improvement networks
engaging staff and building relationships
education about frailty
evidence.
The linked databases in work package 3 comprised 359,945 older people and 1,035,045 observations. The most powerful predictors of four-hour wait and transfer to hospital were age, previous attendance, out-of-hours attendance and call handler designation of urgency.
Drawing upon the previous work packages and working closely with a wide range of patient and professional stakeholders, we developed an system dynamics tool that modelled five evidence-based urgent and emergency care interventions and their impact on the whole system in terms of reducing admissions, readmissions, and hospital related mortality.
Limitations
Across the reviews there was incomplete reporting of interventions. People living with severe frailty and from ethnic minorities were under-represented in the patient/carer interviews. The linked databases did not include patient reported outcomes. The system dynamics model was limited to evidence-based interventions, which could not be modelled conjointly.
Conclusions
We have reaffirmed the poor outcomes frequently experienced by many older people living with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to help including clinicians, service managers and commissioners improve emergency care for older people.
Future work
Future work will focus on refining the system dynamics model, specifically including patient-reported outcome measures and pre-hospital services for older people living with frailty who have urgent care needs.
Study registrations
This study is registered as PROSPERO CRD42018111461. WP 1.2: University of Leicester ethics: 17525-spc3-ls:healthsciences, WP 2: IRAS 262143, CAG 19/CAG/0194, WP 3: IRAS 215818, REC 17/YH/0024, CAG 17/CAG/0024.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme [project number 17/05/96 (Emergency Care for Older People)] and will be published in full in Health and Social Care Delivery Research ; Vol. 11, No. 14. See the NIHR Journals Library website for further project information.
Background
This study aimed to identify the effects of a prospective study applying artificial intelligence-based triage in the clinical field.
Methods
We conducted a systematic review of prospective studies. The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist was used to guide the systematic review and reporting. Three researchers independently extracted the data, assessed the study quality, and presented the findings in a descriptive summary. Inconsistencies between the researchers were resolved after discussion. We manually searched for relevant articles through databases, including CINAHL, Cochrane, Embase, PubMed, ProQuest, and two South Korean search engines (KISS and RISS) from March 9 to April 18, 2023.
Results
Of 1,633 articles, eight met the inclusion criteria for this review. Most studies applied machine learning to triage, and only one study was based on fuzzy logic. Except for one study, all used a 5-level triage classification system, and some developed target-level prediction models. Although the model performance exceeded 70%, the triage prediction accuracy varied from 33.9 to 99.9%. Other outcomes included time reduction, overtriage and undertriage checks, triage risk factors, and outcomes related to patient care and prognosis.
Conclusions
Triage nurses in the emergency department can use artificial intelligence as a supportive means for patient classification. Ultimately, we hope that it will be a resource that can reduce undertriage and positively affect patient health. Verification of the optimal artificial intelligence algorithm by conducting rigorous interdisciplinary research will be a powerful tool to support triage nurses' decision-making in overcrowded emergency departments. Thus, direct nursing activities will increase and become an important factor in improving the quality of nursing care.
Trial registration
We have registered our review in PROSPERO (registration number: CRD***********).
Introduzione: il sovraffollamento è la situazione in cui il normale funzionamento dei pronto soccorso (PS) è limitato dalla sproporzione tra la domanda sanitaria, rappresentata dal numero di pazienti in attesa e in carico, e le risorse logistiche, strumentali e professionali disponibili. Tale fenomeno genera conseguenze negative non solo per i pazienti ma anche per gli operatori e per il sistema. Obiettivo dello studio è di valutare il contributo che potrebbe offrire l’attuazione del modello See and Treat in un PS da circa 45000 accessi per anno. Materiali e Metodi: studio descrittivo retrospettivo. Sono stati analizzati gli accessi registrati presso il PS di un DEA di II° livello – “S. Maria” di Terni – nell’anno 2018, e ne è stata valutata la percentuale eleggibile al percorso See and Treat secondo le indicazioni adottate dalla Regione Toscana. Risultati: Nel 2018 si sono registrati 41.646 accessi con diagnosi di uscita, di cui 1.272 in codice rosso, 11.074 in codice giallo, 25.129 in codice verde e 4.175 in codice bianco. Sono risultati eleggibili al modello See and Treat 4.846 casi, pari al 11,63% dei casi totali e al 16,53% delle “urgenze minori”. Discussione: i dati ottenuti mostrano che il modello See and Treat potrebbe contribuire in maniera significativa alla gestione della casistica a bassa priorità in PS, migliorandone il funzionamento. Conclusioni: le urgenze minori rappresentano la gran parte degli accessi presso il PS. La presenza di infermieri adeguatamente formati può contribuire in maniera significativa alla gestione delle urgenze minori, comportando benefici sia per i professionisti che per gli utenti. Quanto emerso dallo studio può inoltre contribuire a sviluppare il dibattito sulle competenze avanzate dell’infermiere.
Background
Currently there are nationwide discussions about an increased number of emergency patients in German emergency departments. Research questions focus on the respective individual role of family physicians (FP). The aim of this study was to analyse the effect of intimate FP involvement in terms of treatment relevance and frequency of referrals to emergency departments. In addition, FP involvement in out-of-hour practices (in hospitals) and treatment relevance should be considered.Methods
With the help of an anonymous questionnaire, socio-demographic data, the presence of a permanent FP, the type of presentation as well as the treatment relevance and referral rate by FPs, were collected. The patients were interviewed personally in eight internal medicine emergency departments and in four out-of-hour practices in Bavaria, Southern Germany.ResultsOf a total of 1911 patients surveyed, 91% had a permanent FP. 47% of the interviewed patients in the emergency departments had been admitted by FPs/ specialists, 53% were self-presenters or were brought by the rescue service. In out-of-hour practices 93% were self-presenters, 6% FP referrals and 1% back referrals from emergency departments. On average, the relevance of treatment in emergency departments was 70% and in out-of-hour practices 81%.ConclusionsFPs plays an important role in the care of emergency patients and can make an important contribution by preselecting and controlling patients, especially with regard to the group of self-presenters. Out-of-hour practices effectively treat emergency patients without lifethreatening diagnoses and thus relieve emergency department admissions.
Problem definition: We study the estimation of the probability distribution of individual patient waiting times in an emergency department (ED). Whereas it is known that waiting-time estimates can help improve patients’ overall satisfaction and prevent abandonment, existing methods focus on point forecasts, thereby completely ignoring the underlying uncertainty. Communicating only a point forecast to patients can be uninformative and potentially misleading. Methodology/results: We use the machine learning approach of quantile regression forest to produce probabilistic forecasts. Using a large patient-level data set, we extract the following categories of predictor variables: (1) calendar effects, (2) demographics, (3) staff count, (4) ED workload resulting from patient volumes, and (5) the severity of the patient condition. Our feature-rich modeling allows for dynamic updating and refinement of waiting-time estimates as patient- and ED-specific information (e.g., patient condition, ED congestion levels) is revealed during the waiting process. The proposed approach generates more accurate probabilistic and point forecasts when compared with methods proposed in the literature for modeling waiting times and rolling average benchmarks typically used in practice. Managerial implications: By providing personalized probabilistic forecasts, our approach gives low-acuity patients and first responders a more comprehensive picture of the possible waiting trajectory and provides more reliable inputs to inform prescriptive modeling of ED operations. We demonstrate that publishing probabilistic waiting-time estimates can inform patients and ambulance staff in selecting an ED from a network of EDs, which can lead to a more uniform spread of patient load across the network. Aspects relating to communicating forecast uncertainty to patients and implementing this methodology in practice are also discussed. For emergency healthcare service providers, probabilistic waiting-time estimates could assist in ambulance routing, staff allocation, and managing patient flow, which could facilitate efficient operations and cost savings and aid in better patient care and outcomes.
Supplemental Material: The online supplement is available at https://doi.org/10.1287/msom.2023.1210 .
Objective
Suboptimal transitional care (ie, needs assessment and coordination of follow-up care) in the emergency department (ED) is an important cause of ED revisits and hospital admissions and may potentially harm patients, especially frail older adults. We aimed to systematically review the effect of ED-based interventions by health professionals who are dedicated to providing transitional care to older adults.
Design
Systematic review.
Measurements
We searched five biomedical databases for published (quasi)experimental studies evaluating the effects of health professionals in the ED dedicated to providing transitional care to older ED patients on clinical, process and/or service use outcomes. Reviewers screened studies for relevance and assessed methodological quality with published criteria (Robins-1 and the Cochrane risk of bias tool). Data were synthesised around study and intervention characteristics and outcomes of interest.
Results
From the 6561 references initially extracted from the databases, 12 studies were eligible for inclusion. Two types of interventions were identified, namely, individual needs assessment of ED patients (8 studies; 75%) and discharge planning and coordination of services (4 studies; 25%). Structured individual needs assessment was associated with a significant decrease in hospital admissions, hospital readmissions and ED revisits. Individualised discharge plans from the ED were associated with a significant decrease in ED revisits and hospital readmission. The overall methodological quality of the included studies was relatively low.
Conclusions
Comprehensive assessment of patient needs and ED discharge planning and coordination of services by health professionals interested in transitional care can help optimise the transition of care for older ED patients and reduce the risk of costly and potentially harmful (re)admissions for this population. However, more robust research is needed on the effectiveness of these interventions aiming to improve clinical, process and service use outcomes.
PROSPERO registration number
CRD42021237345.
Background
During a 6-year period, several process changes were introduced at the emergency department (ED) to decrease crowding, such as the implementation of a general practitioner cooperative (GPC) and additional medical staff during peak hours. In this study, we assessed the effects of these process changes on three crowding measures: patients’ length of stay (LOS), the modified National ED OverCrowding Score (mNEDOCS), and exit block while taking into account changing external circumstances, such as the COVID-19 pandemic and centralization of acute care.
Methods
We determined time points of the various interventions and external circumstances and built an interrupted time-series (ITS) model per outcome measure. We analyzed changes in level and trend before and after the selected time points using ARIMA modeling, to account for autocorrelation in the outcome measures.
Results
Longer patients’ ED LOS was associated with more inpatient admissions and more urgent patients. The mNEDOCS decreased with the integration of the GPC and the expansion of the ED to 34 beds and increased with the closure of a neighboring ED and ICU. More exit blocks occurred when more patients with shortness of breath and more patients > 70 years of age presented to the ED. During the severe influenza wave of 2018–2019, patients’ ED LOS and the number of exit blocks increased.
Conclusions
In the ongoing battle against ED crowding, it is pivotal to understand the effect of interventions, corrected for changing circumstances and patient and visit characteristics. In our ED, interventions which were associated with decreased crowding measures included the expansion of the ED with more beds and the integration of the GPC on the ED.
The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes.
To determine whether patients who are not admitted to hospital after attending an emergency department during shifts with long waiting times are at risk for adverse events.
Population based retrospective cohort study using health administrative databases. Setting High volume emergency departments in Ontario, Canada, fiscal years 2003-7.
All emergency department patients who were not admitted (seen and discharged; left without being seen).
Risk of adverse events (admission to hospital or death within seven days) adjusted for important characteristics of patients, shift, and hospital.
13,934,542 patients were seen and discharged and 617,011 left without being seen. The risk of adverse events increased with the mean length of stay of similar patients in the same shift in the emergency department. For mean length of stay ≥ 6 v <1 hour the adjusted odds ratio (95% confidence interval) was 1.79 (1.24 to 2.59) for death and 1.95 (1.79 to 2.13) for admission in high acuity patients and 1.71 (1.25 to 2.35) for death and 1.66 (1.56 to 1.76) for admission in low acuity patients). Leaving without being seen was not associated with an increase in adverse events at the level of the patient or by annual rates of the hospital.
Presenting to an emergency department during shifts with longer waiting times, reflected in longer mean length of stay, is associated with a greater risk in the short term of death and admission to hospital in patients who are well enough to leave the department. Patients who leave without being seen are not at higher risk of short term adverse events.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
It has been estimated that full implementation of the Affordable Care Act will extend coverage to thirty-two million previously uninsured Americans. However, rapidly rising health care costs could thwart that effort. Since 1988 Intermountain Healthcare has applied to health care delivery the insights of W. Edwards Deming's process management theory, which says that the best way to reduce costs is to improve quality. Intermountain achieved such quality-based savings through measuring, understanding, and managing variation among clinicians in providing care. Intermountain created data systems and management structures that increased accountability, drove improvement, and produced savings. For example, a new delivery protocol helped reduce rates of elective induced labor, unplanned cesarean sections, and admissions to newborn intensive care units. That one protocol saves an estimated $50 million in Utah each year. If applied nationally, it would save about $3.5 billion. "Organized care" along these lines may be central to the long-term success of health reform.
We sought to measure the self-reported implementation of the crowding solutions outlined in the 2008 American College of Emergency Physicians (ACEP) Boarding Task Force report "Emergency Department Crowding: High-Impact Solutions." We also tested the hypothesis that the self-reported crowding of emergency departments (EDs) was positively associated with the implementation of these solutions.
In early 2009, we mailed a survey to all medical or nursing directors from EDs in four US states asking for information regarding their EDs in 2008. Geographic information about the EDs was included in the analysis, along with survey responses about their ED capacity status and implementation of specific ACEP crowding solutions.
A total of 284 of 351 EDs responded (81%). The majority of EDs were in urban areas (56%), non-teaching hospitals (93%), and not critical access hospitals (76%). The percentage of EDs "over capacity" ranged from 10-49% in each state. The mean number of crowding solutions used in EDs that were at or over capacity ranged from 3.6-4.6 in each state. EDs with visit volumes greater than or equal to three patients/hour were more likely to be over capacity than at capacity or at a good balance (46% vs. 31% and 15%, respectively). In terms of the use of high-impact crowding solutions, hospitals over capacity were more likely to utilize inpatient full capacity protocols (40% vs. 25% and 25%) but not inpatient discharge coordination (29% vs. 27% and 34%) or surgical schedule smoothing (31% vs. 28% and 32%). Hospitals over capacity were also more likely to have fast track units (44% vs. 32% and 16%) and physicians at triage (48% vs. 29% and 17%).
Less than half of EDs in each state reported operation above capacity. Implementation of some crowding solutions was more common in the above-capacity EDs, although these solutions were not consistently used across geographic locations and hospitals. Given that the majority of EDs were not over capacity, the implementation of these solutions does not seem to be universally necessary.
TWO CROWDING METRICS ARE OFTEN USED TO MEASURE EMERGENCY DEPARTMENT (ED) CROWDING: the occupancy rate and the emergency department work index (EDWIN) score. To evaluate these metrics for applicability in our community ED, we sought to measure their correlation with the number of patients who left without being seen (LWBS) and determine if either, or both, correlated with our daily LWBS rate. We hypothesized a statistically significant positive correlation between the number of patients who LWBS and both crowding metrics.
We performed a retrospective observational study by reviewing data on all patients who LWBS from December 1, 2007, to February 29, 2008. Occupancy rates and EDWIN scores were obtained through our electronic patient tracking board. We identified LWBS status by searching the final disposition entered into our electronic medical record. We measured the correlation between each crowding metric averaged over each 24-hour day and the number of patients who LWBS per 24-hour day using Spearman's rank correlation, and created receiver operator characteristic (ROC) curves to quantify the discriminatory power of occupancy rate and EDWIN score for predicting more than two patients per day who LWBS.
We identified 1,193 patients who LWBS during the study period, including patients who registered but then left the waiting room (733), as well as those who left before: registration (71), triage (75), seeing a physician (260), or final disposition (54). The number of patients who LWBS per day ranged from one to 30, with a mean of 13 and median of 11 (IQR 6 to 19). The daily number of patients who LWBS showed a positive correlation with the average daily occupancy rate (Spearman's rho = 0.771, p = 0.01) and with average daily EDWIN score (Spearman's rho = 0.67, p< .001). Area under the ROC curve for occupancy rate was .97 (95% CI .93 to 1.0) and for EDWIN score was .94 (95% CI .89 to 1.0).
Average daily occupancy rates and EDWIN scores both correlate positively with, and have excellent discriminatory power for, the number of patients who LWBS in our ED; however, the scale of our EDWIN scores differs from that obtained at other institutions. For studies of crowding, occupancy rate may be the more useful metric due to its ease of calculation.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
To quantify any relationship between emergency department (ED) overcrowding and 10-day patient mortality.
Retrospective stratified cohort analysis of three 48-week periods in a tertiary mixed ED in 2002-2004. Mean "occupancy" (a measure of overcrowding based on number of patients receiving treatment) was calculated for 8-hour shifts and for 12-week periods. The shifts of each type in the highest quartile of occupancy were classified as overcrowded.
All presentations of patients (except those arriving by interstate ambulance) during "overcrowded" (OC) shifts and during an equivalent number of "not overcrowded" (NOC) shifts (same shift, weekday and period).
In-hospital death of a patient recorded within 10 days of the most recent ED presentation.
There were 34 377 OC and 32 231 NOC presentations (736 shifts each); the presenting patients were well matched for age and sex. Mean occupancy was 21.6 on OC shifts and 16.4 on NOC shifts. There were 144 deaths in the OC cohort and 101 in the NOC cohort (0.42% and 0.31%, respectively; P=0.025). The relative risk of death at 10 days was 1.34 (95% CI, 1.04-1.72). Subgroup analysis showed that, in the OC cohort, there were more presentations in more urgent triage categories, decreased treatment performance by standard measures, and a higher mortality rate by triage category.
In this hospital, presentation during high ED occupancy was associated with increased in-hospital mortality at 10 days, after controlling for seasonal, shift, and day of the week effects. The magnitude of the effect is about 13 deaths per year. Further studies are warranted.
The purpose of this systematic review was to critically review and synthesize current evidence and the methodological quality of nonpharmacological infection-prevention interventions in long-term care (LTC) facilities for older adults. Two reviewers searched three electronic databases for studies published over the last decade assessing randomized and nonrandomized trials designed to reduce infections in older adults in which primary outcomes were infection rates and reductions of risk factors related to infections. To establish clarity and standardized reporting of findings, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used. Data extracted included study design, sample size, type and duration of interventions, outcome measures reported, and findings. Two reviewers independently assessed study quality using a validated quality assessment tool. Twenty-four articles met inclusion criteria; the majority were randomized control trials (67%) in which the primary purpose was to reduce pneumonia (66%). Thirteen (54%) studies reported statistically significant results in favor of interventions on at least one of their outcome measures. The methodological clarity of available evidence was limited, placing them at potential risk of bias. Gaps and inconsistencies surrounding interventions in LTC are evident. Future interventional studies need to enhance methodological rigor using clearly defined outcome measures and standardized reporting of findings.
Growing use of U.S. emergency departments (EDs), cited as a key contributor to rising health care costs, has become a leading target of health care reform. ED visit rates increased by more than a third between 1997 and 2007, and EDs are increasingly the safety net for underserved patients, particularly adult Medicaid beneficiaries.(1) Although much attention has been paid to increasing ED use, the ED's changing role in our health care system has been less thoroughly examined. EDs serve as a hub for prehospital emergency medical systems, an acute diagnostic and treatment center, a primary safety net, and a 24/7 . . .
Study objective:
We evaluate recent trends in emergency department (ED) crowding and its potential causes by analyzing ED occupancy, a proxy measure for ED crowding.
Methods:
We analyzed data from the annual National Hospital Ambulatory Medical Care Surveys from 2001 to 2008. The surveys abstract patient records from a national sample of hospital EDs to generate nationally representative estimates of visits. We used time of ED arrival and length of ED visit to calculate mean and hourly ED occupancy.
Results:
During the 8-year study period, the number of ED visits increased by 1.9% per year (95% confidence interval 1.2% to 2.5%), a rate 60% faster than population growth. Mean occupancy increased even more rapidly, at 3.1% per year (95% confidence interval 2.3% to 3.8%), or 27% during the 8 study years. Among potential factors associated with crowding, the use of advanced imaging increased most, by 140%. But advanced imaging had a smaller effect on the occupancy trend than other more common throughput factors, such as the use of intravenous fluids and blood tests, the performance of any clinical procedure, and the mention of 2 or more medications. Of patient characteristics, Medicare payer status and the age group 45 to 64 years accounted for small disproportionate increases in occupancy.
Conclusion:
Despite repeated calls for action, ED crowding is getting worse. Sociodemographic changes account for some of the increase, but practice intensity is the principal factor driving increasing occupancy levels. Although hospital admission generated longer ED stays than any other factor, it did not influence the steep trend in occupancy.
Over the past decade, emergency departments (ED) have encountered major challenges due to increased crowding and a greater public focus on quality measurement and quality improvement. Responding to these challenges, many EDs have worked to improve their processes and develop new and innovative models of care delivery. Urgent Matters has contributed to ED quality and patient flow improvement by working with hospitals throughout the United States. Recognizing that EDs across the country are struggling with many of the same issues, Urgent Matters—a program funded by the Robert Wood Johnson Foundation (RWJF)—has sought to identify, develop, and disseminate innovative approaches, interventions, and models to improve ED flow and quality. Using a variety of techniques, such as learning networks (collaboratives), national conferences, e-newsletters, webinars, best practices toolkits, and social media, Urgent Matters has served as a thought leader and innovator in ED quality improvement initiatives. The Urgent Matters Seven Success Factors were drawn from the early work done by program participants and propose practical guidelines for implementing and sustaining ED improvement activities. This article chronicles the history, activities, lessons learned, and future of the Urgent Matters program.
ACADEMIC EMERGENCY MEDICINE 2011; 18:1392–1399 © 2011 by the Society for Academic Emergency Medicine
The objective was to assess the relationship between emergency department (ED) crowding and timeliness of antibiotic administration to neonates presenting with fever in a pediatric ED.
This was a retrospective cohort study of febrile neonates (aged 0-30 days) evaluated for serious bacterial infections (SBIs) in a pediatric ED from January 2006 to January 2008. General linear models were used to evaluate the association of five measures of ED crowding with timeliness of antibiotic administration, controlling for patient characteristics. A secondary analysis was conducted to determine which part of the ED visit for this population was most affected by crowding.
A total of 190 patients met inclusion criteria. Mean time to first antibiotic was 181.7 minutes (range = 18-397 minutes). At the time of case presentation, the number of patients waiting in the waiting area, total number of hours spent in the ED by current ED patients, number of ED patients awaiting admission, and hourly boarding time were all positively associated with longer times to antibiotic. The time from patient arrival to room placement exhibited the strongest association with measures of crowding.
Emergency department crowding is associated with delays in antibiotic administration to the febrile neonate despite rapid recognition of this patient population as a high-risk group. Each component of ED crowding, in terms of input, throughput, and output factors, was associated with delays. Further work is required to develop processes that foster a more rapid treatment protocol for these high-risk patients, regardless of ED crowding pressures.
We aimed to investigate the effect of crowding on the hospital mortality of pediatric patients from adult-pediatric mixed emergency departments (EDs).
We used the National Emergency Department Information System database, which included demographic, clinical, diagnostic, and procedural information with all emergency patients visiting to 116 EDs from Korea since 2004. We enrolled EDs with mean length of stay of more than 6 hours. Study period was from January 2006 to December 2008. Pediatric patients younger than 15 years admitted from these EDs were study targets. We calculated the mean patient volume (mean number of patients in the ED) over 8-hour shift for each hospital. When the volume reached the highest quartile, the period was considered as crowded. Patients who came during the overcrowded period were defined as the crowded group. We performed a Kaplan-Meier analysis, and hazard ratio and 95% confidence intervals (95% CIs) were calculated using a Cox proportional hazards regression model.
A total of 34 EDs and 125,031 admitted pediatric patients were included; 74,152 (59.3%) were male, and the mean age was 3.84 (95% CI, 3.82-3.86) years; 35,924 (28.7%) were determined as the crowded group. The 30-day mortality rates were 0.4% and 0.3% (P = 0.063) for the crowded group and for the noncrowded group, respectively. The hazard ratio for hospital mortality of the crowded group was 1.230 (95% CI, 1.019-1.558).
The ED crowding was associated with increased hazard for hospital mortality for pediatric patients in mixed EDs.
Health care reform in Massachusetts improved access to health insurance, but the extent to which reform affected utilization of the emergency department (ED) for conditions potentially amenable to primary care is unclear. Our objective is to determine the relationship between health reform and ED use for low-severity conditions.
We studied ED visits, using a convenience sample of 11 Massachusetts hospitals for identical 9-month periods before and after health care reform legislation was implemented in 2006. Individuals most affected by the health reform law (the uninsured and low-income populations covered by the publicly subsidized insurance products) were compared with individuals unlikely to be affected by the legislation (those with Medicare or private insurance). Our main outcome measure was the rate of overall and low-severity ED visits for the study population and the comparison population during the period before and after health reform implementation.
Total visits increased from 424,878 in 2006 to 442,102 in 2008. Low-severity visits among publicly subsidized or uninsured patients decreased from 43.8% to 41.2% of total visits for that group (difference=2.6%; 95% confidence interval [CI] 2.25% to 2.85%), whereas low-severity visits for privately insured and Medicare patients decreased from 35.7% to 34.9% of total visits for that group (difference=0.8%; 95% CI 0.62% to 0.98%), for a difference in differences of 1.8% (95% CI 1.7% to 1.9%).
Although overall ED volume continues to increase, Massachusetts health reform was associated with a small but statistically significant decrease in the rate of low-severity visits for those populations most affected by health reform compared with a comparison population of individuals less likely to be affected by the reform. Our findings suggest that access to health insurance is only one of a multitude of factors affecting utilization of the ED.
Despite consensus regarding the conceptual foundation of crowding, and increasing research on factors and outcomes associated with crowding, there is no criterion standard measure of crowding. The objective was to conduct a systematic review of crowding measures and compare them in conceptual foundation and validity.
This was a systematic, comprehensive review of four medical and health care citation databases to identify studies related to crowding in the emergency department (ED). Publications that "describe the theory, development, implementation, evaluation, or any other aspect of a 'crowding measurement/definition' instrument (qualitative or quantitative)" were included. A "measurement/definition" instrument is anything that assigns a value to the phenomenon of crowding in the ED. Data collected from papers meeting inclusion criteria were: study design, objective, crowding measure, and evidence of validity. All measures were categorized into five measure types (clinician opinion, input factors, throughput factors, output factors, and multidimensional scales). All measures were then indexed to six validation criteria (clinician opinion, ambulance diversion, left without being seen (LWBS), times to care, forecasting or predictions of future crowding, and other).
There were 2,660 papers identified by databases; 46 of these papers met inclusion criteria, were original research studies, and were abstracted by reviewers. A total of 71 unique crowding measures were identified. The least commonly used type of crowding measure was clinician opinion, and the most commonly used were numerical counts (number or percentage) of patients and process times associated with patient care. Many measures had moderate to good correlation with validation criteria.
Time intervals and patient counts are emerging as the most promising tools for measuring flow and nonflow (i.e., crowding), respectively. Standardized definitions of time intervals (flow) and numerical counts (nonflow) will assist with validation of these metrics across multiple sites and clarify which options emerge as the metrics of choice in this "crowded" field of measures.
The purpose of this review was to summarize the findings of published reports that investigated quality-related outcomes and emergency department (ED) crowding. Of 276 data-based articles, 23 reported associations between patient outcomes and crowding. These articles were grouped into 3 categories: delay in treatment, decreased satisfaction, and increased mortality. Although these studies suggest that crowding results in poor outcomes, it is possible that other factors such as nursing care contribute to these adverse outcomes. Nursing care has been shown to contribute to both positive and negative patient outcomes in other settings. Building an understanding of how ED crowding affects the practice of the emergency nurse is essential to examining how nursing care, surveillance, and communication impact outcomes of emergency patients. Investigation into nurse-sensitive quality indicators in the ED has potential to develop strategies that deliver high quality of care, regardless of crowded conditions.
While emergency department (ED) crowding is a worldwide problem, few studies have demonstrated associations between crowding and outcomes. The authors examined whether ED crowding was associated with adverse cardiovascular outcomes in patients with chest pain syndromes (chest pain or related complaints of possible cardiac origin).
A retrospective analysis was performed for patients >or=30 years of age with chest pain syndrome admitted to a tertiary care academic hospital from 1999 through 2006. The authors compared rates of inpatient adverse outcomes from ED triage to hospital discharge, defined as delayed acute myocardial infarction (AMI), heart failure, hypotension, dysrhythmias, and cardiac arrest, which occurred after ED arrival using five separate crowding measures.
Among 4,574 patients, 251 (4%) patients developed adverse outcomes after ED arrival; 803 (18%) had documented acute coronary syndrome (ACS), and of those, 273 (34%) had AMI. Compared to less crowded times, ACS patients experienced more adverse outcomes at the highest waiting room census (odds ratio [OR] = 3.7, 95% confidence interval [CI] = 1.3 to 11.0) and patient-hours (OR = 5.2, 95% CI = 2.0 to 13.6) and trended toward more adverse outcomes during time of high ED occupancy (OR = 3.1, 95% CI = 1.0 to 9.3). Adverse outcomes were not significantly more frequent during times with the highest number of admitted patients (OR = 1.6, 95% CI = 0.6 to 4.1) or the highest trailing mean length of stay (LOS) for admitted patients transferred to inpatient beds within 6 hours (OR = 1.5, 95% CI = 0.5 to 4.0). Patients with non-ACS chest pain experienced more adverse outcomes during the highest waiting room census (OR = 3.5, 95% CI = 1.4 to 8.4) and patient-hours (OR = 4.3, 95% CI = 2.6 to 7.3), but not occupancy (OR = 1.8, 95% CI = 0.9 to 3.3), number of admitted patients (OR = 0.6, 95% CI 0.4 to 1.1), or trailing LOS for admitted patients (OR = 1.2, 95% CI = 0.6 to 2.0).
There was an association between some measures of ED crowding and a higher risk of adverse cardiovascular outcomes in patients with both ACS-related and non-ACS-related chest pain syndrome.
The objective was to study the association between factors related to emergency department (ED) crowding and patient satisfaction.
The authors performed a retrospective cohort study of all patients admitted through the ED who completed Press-Ganey patient satisfaction surveys over a 2-year period at a single academic center. Ordinal and binary logistic regression was used to study the association between validated ED crowding factors (such as hallway placement, waiting times, and boarding times) and patient satisfaction with both ED care and assessment of satisfaction with the overall hospitalization.
A total of 1,501 hospitalizations for 1,469 patients were studied. ED hallway use was broadly predictive of a lower likelihood of recommending the ED to others, lower overall ED satisfaction, and lower overall satisfaction with the hospitalization (p < 0.05). Prolonged ED boarding times and prolonged treatment times were also predictive of lower ED satisfaction and lower satisfaction with the overall hospitalization (p < 0.05). Measures of ED crowding and ED waiting times predicted ED satisfaction (p < 0.05), but were not predictive of satisfaction with the overall hospitalization.
A poor ED service experience as measured by ED hallway use and prolonged boarding time after admission are adversely associated with ED satisfaction and predict lower satisfaction with the entire hospitalization. Efforts to decrease ED boarding and crowding might improve patient satisfaction.
Crowding is an increasingly common occurrence in hospital-based emergency departments (EDs) across the globe. This 2-article series offers an ethical and policy analysis of ED crowding. Part 1 begins with a discussion of terms used to describe this situation and proposes that the term "crowding" be preferred to "overcrowding." The article discusses definitions, measures, and causes of ED crowding and concludes that the inability to transfer emergency patients to inpatient beds and resultant boarding of admitted patients in the ED are among the root causes of ED crowding. Finally, the article identifies and describes a variety of adverse moral consequences of ED crowding, including increased risks of harm to patients, delays in providing needed care, compromised privacy and confidentiality, impaired communication, and diminished access to care. Part 2 of the series examines barriers to resolving the problem of ED crowding and strategies proposed to overcome those barriers.
An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated.
The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs).
We reviewed the English-language literature for the years 1989-2007 for case series, cohort studies, and clinical trials addressing crowding's effects on COOs. Keywords searched included "ED crowding,"ED overcrowding,"mortality,"time to treatment,"patient satisfaction,"quality of care," and others.
A total of 369 articles were identified, of which 41 were kept for inclusion. Study quality was modest; most articles reflected observational work performed at a single institution. There were no randomized controlled trials. ED crowding is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ED against medical advice or without being seen. Crowding is not associated with delays in reperfusion for patients with ST-elevation myocardial infarction. Insufficient data were available to draw conclusions on crowding's effects on patient satisfaction and other quality endpoints.
A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care, such as time to treatment for patients with time-sensitive conditions such as pneumonia. At least two domains of quality of care, safety and timeliness, are compromised by ED crowding.
This report describes ambulatory care visits to hospital emergency departments (ED's) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. Highlights of trends in ED utilization from 1992 through 1999 are also presented.
The data presented in this report were collected from the 1999 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability survey of visits to hospital emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. Trends are based on NHAMCS data for 1992, 1993-94, 1995-96, 1997-98, and 1999.
During 1999, an estimated 102.8 million visits were made to hospital ED's in the United States, about 37.8 visits per 100 persons. The volume of ED visits increased by 14 percent from 1992 through 1999, though no trend was observed in the overall population-based visit rates. There was a significant increase in the visit rate for black persons 75 years of age and over. In 1999, persons 75 years of age and over had the highest ED visit rate and 41.5 percent of these patients arrived by ambulance. There were an estimated 37.6 million injury-related ED visits during 1999, or 13.8 visits per 100 persons. Seventy-four percent of injury-related ED visits were made by persons under 45 years of age. Injury visit rates were higher for males than females in each age group under 45 years. The case mix of visits at ED's changed since 1992, with a greater percent of visits presenting with illness rather than injury conditions. Abdominal pain, chest pain, fever, and headache were the leading patient complaints accounting for one-fifth of all visits. Acute upper respiratory infection was the leading illness-related diagnosis at ED visits. Increases were observed in visits where no complete diagnosis could be made (16.2 percent of visits in 1999). Diagnostic and/or screening services were provided at 89.0 percent of visits, procedures were performed at 42.5 percent of visits, and medications were provided at 72.5 percent of visits. Pain relief drugs accounted for 31.1 percent of the medications mentioned. Trend data from 1992 indicated that the use of medications at ED visits increased. In 1999, approximately 13 percent of ED visits ended in hospital admission. Facility-level data indicated that there is variation among hospital ED's with respect to case mix, number of services provided, and case disposition distributions, especially the percent admitted to the hospital.
Patients who leave without being seen (LWBS) can be an indicator of patient satisfaction and quality for emergency departments (ED). The objective of this study was to develop a model to determine factors associated with patients who LWBS.
A modified case-crossover design to determine the transient effects on the risk of acute events was used. Over a four-month period, time intervals when patients LWBS were matched (within two weeks), according to time of day and day of week, with time periods when patients did not LWBS. Factors considered were percentage of ED bed capacity, acuity of ED patients, length of stay of discharged patients in the ED, patients awaiting an admission bed in the ED, inpatient floor capacity, intensive care unit capacity, and the characteristics of the attending physician in charge. McNemar test, Wilcoxon signed-rank test, and conditional logistic regression analyses were used to determine significant variables.
Over the study period, there were 11,652 visits, of which 213 (1.8%) resulted in patients who LWBS. Measures of inpatient capacity were not associated with patients who LWBS and ED capacity was only associated when >100%. This association increased with increasing capacity. Other significant factors were older age (p < 0.01) and completion of an emergency medicine residency (p < 0.01) of the physician in charge. When factors were considered in a multivariate model, ED capacity >140% (odds ratio, 1.96; 95% confidence interval = 1.22 to 3.17) and noncompletion of an emergency medicine residency (odds ratio, 1.85; 95% confidence interval = 1.17 to 2.93) were most important.
ED capacity >100% is associated with patients who LWBS and is most significant at 140% capacity. ED capacity of 100% may not be a sensitive measure for overcrowding. Physician factors, especially emergency medicine training, also appear to be important when using LWBS as a quality indicator.
We hypothesize that the number of patients who leave without being seen is correlated with the simple-to-use National Emergency Department Overcrowding Scale (NEDOCS).
Results of a 6-item ED overcrowding scale (NEDOCS) were collected prospectively over a 17-day study period. The following additional data were extracted from records for each 2-hour study period: (1) number of registered patients, (2) number of ambulances that arrived, and (3) number of patients signed in that hour who eventually left without being seen. Spearman correlation coefficients were computed for the leaving without being seen (LWBS) rate with the NEDOCS score at the time of patient presentation and 2, 4, and 6 hours later.
The study period represents two hundred fourteen 2-hour periods. The LWBS rate was determined for 100% of the times; NEDOCS scores were determined for a sampling of 62% of the times spread equally over all hours of the day and days of the week. Correlation between the NEDOCS score and LWBS was 0.665.
The NEDOCS score is well correlated with LWBS.
Emergency department crowding has the potential to cause undesirable outcomes. We evaluated ED access and provider and patient assessments of quality.
This multimethod study, done in an urban academic ED, included descriptive analysis of administrative records, paired physician and nurse provider surveys, and pre- or postpatient surveys regarding expectations and experiences. Our outcomes were rates and characteristics of patients who left without being seen (LWBS), provider ratings of crowding/compromised care, and patient satisfaction.
During data collection periods, 11743 patients registered, and 9% LWBS. Patients who LWBS tended to be younger than 45 years (relative risk [RR] = 1.7; 95% confidence interval [CI], 1.5-1.9), of nonurgent/stable triage acuity (RR = 3.1; 95% CI, 2.5-3.8), and without insurance (RR = 1.5; 95% CI, 1.3-1.7). Seventy-four percent of all patients had insurance, and 28% were private. Doctors and nurses had 81% agreement (kappa = 0.54) in their assessment of crowded conditions, which were temporally associated with LWBS rates (P < .01). In 47% of 57 shifts, at least 1 provider felt that crowding was compromising quality of care. Of 423 sequential ED waiting room patients approached, 310 (73%) enrolled and 174 (56%) of these completed phone follow-up. On average, patients felt that they should be seen within 1 hour but expected to wait for 2.1 hours. Patient's perceived that wait times on follow-up averaged 3.5 hours, 5+ hours for LWBS patients. Visit satisfaction was inversely related to patient's perceived wait times.
We find that ED crowding increased LWBS rates and patient satisfaction. Systemwide changes in ED organization will be necessary for the ED to fulfill its role as a safety net provider and meet public health needs during disaster surge capacity.
Reneging (i.e., leaving without being seen) is an important outcome of emergency department (ED) overcrowding. The input-throughput-output conceptualization of ED patient flow is helpful in understanding and measuring the impact of various factors on this outcome.
To quantify the impact of input and output factors on ED renege rate.
The authors used patient-level and system-level data from multiple sources in their institution to build logistic regression models, with reneging as the dependent variable. This approach provides the impact of each input and output factor on renege rate expressed as an odds ratio (OR).
The OR for reneging attributable to the difference between the 80th and 20th percentile values for inpatient bed utilization is 1.05. Comparing 80th and 20th percentile values for boarded ED admits as of 7 AM, the OR is 1.73; for daily ED arrivals, the OR is 2.00; and for admission percentage, the OR is 1.12. The OR for evening versus morning patient arrival time is 3.9 and for patient arrival on a Monday versus a Sunday is 2.7. The OR for reneging for a patient presenting on Monday evening versus Sunday morning is 10.5.
The effects of ED input and output factors on renege rate are significant and quantifiable. At least some of the variation in these factors and subsequently their effects are predictable, suggesting that further refinement in the management of ED and inpatient resources could affect improvement in ED renege rate. Continued efforts at quantifying the effects are warranted.
We seek to determine the impact of emergency department (ED) crowding on delays in antibiotic administration for patients with community-acquired pneumonia.
We performed a retrospective cohort study of adult patients admitted with community-acquired pneumonia from January 1, 2003, to April 31, 2005, at a single, urban academic ED. The main outcome was a delay (>4 hours from arrival) or nonreceipt of antibiotics in the ED. Eight ED crowding measures were assigned at triage. Multivariable regression and bootstrapping were used to test the adjusted impact of ED crowding measures of delayed (or no) antibiotics. Predicted probabilities were then calculated to assess the magnitude of the impact of ED crowding on the probability of delayed (or no) antibiotics.
In 694 patients, 44% (95% confidence interval [CI] 40% to 48%) received antibiotics within 4 hours and 92% (95% CI 90% to 94%) received antibiotics in the ED. Increasing levels of ED crowding were associated with delayed (or no) antibiotics, including waiting room number (odds ratio [OR] 1.05 for each additional waiting room patient [95% CI 1.01 to 1.10]) and recent ED length of stay for admitted patients (OR 1.14 for each additional hour [95% CI 1.04 to 1.25]). When the waiting room and recent length of stay were both at the lowest quartiles (ie, not crowded), the predicted probability of delayed (or no) antibiotics within 4 hours was 31% (95% CI 21% to 42%); when both were at the highest quartiles, the predicted probability was 72% (95% CI 61% to 81%).
ED crowding is associated with delayed and nonreceipt of antibiotics in the ED for patients admitted with community-acquired pneumonia.
The authors measured the association between emergency department (ED) crowding and patient and provider perceptions about whether patient care was compromised.
This was a cross-sectional study of patients admitted from the ED and their providers. Surveys of patients, nurses, and resident physicians were linked. The primary outcome was agreement or strong agreement on a five-item scale assessing whether ED crowding compromised care. Logistic regression was used to determine the association between the primary outcome and measures of ED crowding.
Of 741 patients approached, 644 patients consented (87%); 703 resident physician surveys (95%) and 716 nursing surveys (97%) were completed. A total of 106 patients (16%), 86 residents (12%), and 173 nurses (24%) reported that care was compromised by ED crowding. In 252 cases (35%), one or more respondents reported that care was compromised. There was poor agreement over whose care was compromised. For patients, independent predictors of compromised care were waiting room time (odds ratio [OR], 1.05 for each additional 10-minute wait [95% confidence interval {CI} = 1.02 to 1.09]) and being surveyed in a hallway bed (OR, 2.02 [95% CI = 1.12 to 3.68]). Predictors of compromised care for nurses included waiting room time (OR, 1.05 for each additional 10-minute wait [95% CI = 1.01 to 1.08]), number of patients in the waiting room (OR, 1.05 for each additional patient waiting [95% CI = 1.02 to 1.07]), and number of admitted patients waiting for an inpatient bed (OR, 1.08 for each additional patient [95% CI = 1.03 to 1.12]). For residents, predictors of compromised care were patient/nurse ratio (OR, 1.39 for a one-unit increase [95% CI = 1.09 to 1.20]) and number of admitted patients waiting for an inpatient bed (OR, 1.14 for each additional patient [95% CI = 1.10 to 1.75]).
ED crowding is associated with perceptions of compromised emergency care. There is considerable variability among nurses, patients, and resident physicians over which factors are associated with compromised care, whose care was compromised, and how care was compromised.
In the Boarders in the Emergency Department (BED) study the impact of overcrowding due to boarders on patients' mortality and the likelihood of being diagnosed with methicillin resistant Staphylococcus aureus (MRSA) during admission was examined. With regard to efficiency, the impact of overcrowding on the time to first medical assessment for admitted patients, the number of patients leaving without being seen, and the rate of admission as a percentage of total emergency department attendances was explored.
The retrospective cohort analysis study of all emergency department admissions was performed using information accessed via the Diver Solution. The software integrated information from several databases.
The average number of patients awaiting hospital admission in the emergency department at 09:00 was 20.4 (range 0-45). The average duration of stay in the emergency department following the decision to admit was 16.1 h (range 0-161 h). The number who did not wait (DNW) to be seen was strongly correlated with the time waiting for medical assessment, which in turn was correlated with the total number of attendances to the emergency department (p<0.001). The elderly waited longer for admission and had the highest mortality and the highest chance of being diagnosed with MRSA during their overall admission.
It is wrong for patients who are sick enough to require admission to hospital to be kept in the emergency department, and the entire health system must respond to their plight.
Emergency department (ED) crowding represents an international crisis that may affect the quality and access of health care. We conducted a comprehensive PubMed search to identify articles that (1) studied causes, effects, or solutions of ED crowding; (2) described data collection and analysis methodology; (3) occurred in a general ED setting; and (4) focused on everyday crowding. Two independent reviewers identified the relevant articles by consensus. We applied a 5-level quality assessment tool to grade the methodology of each study. From 4,271 abstracts and 188 full-text articles, the reviewers identified 93 articles meeting the inclusion criteria. A total of 33 articles studied causes, 27 articles studied effects, and 40 articles studied solutions of ED crowding. Commonly studied causes of crowding included nonurgent visits, "frequent-flyer" patients, influenza season, inadequate staffing, inpatient boarding, and hospital bed shortages. Commonly studied effects of crowding included patient mortality, transport delays, treatment delays, ambulance diversion, patient elopement, and financial effect. Commonly studied solutions of crowding included additional personnel, observation units, hospital bed access, nonurgent referrals, ambulance diversion, destination control, crowding measures, and queuing theory. The results illustrated the complex, multifaceted characteristics of the ED crowding problem. Additional high-quality studies may provide valuable contributions toward better understanding and alleviating the daily crisis. This structured overview of the literature may help to identify future directions for the crowding research agenda.
The effect of emergency department crowding on clinically oriented outcomes Academic Emergency Medicine FastStats. Hospital utilization The association between crowding and mortality in admitted pediatric patients from mixed adult-pediatric emergency departments in Korea
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Emergency department overcrowding: Analysis of the factors of renege rate
- Asaro
ED crowding is associated with variable perceptions of care compromise
- Pines
The effect of emergency department crowding on patient outcomes: A literature review
- Johnson
Factors associated with patients who leave without being seen
- Polevoi